Dear Mr Brown – Nurses taking the pledge won’t fix the Staffordshire problem

Has the Prime Minister’s “front line” commission report on nursing and midwifery delivered a damp squib?  I rather think so, if Recommendation 1 is anything to go by.  It states: “Nurses and midwives must renew their pledge to society and service users to tackle unacceptable variations in standards and deliver high quality, compassionate care.”

The nettle ungrasped

In MAC’s view the key question about the Staffordshire scandal must be “where were the nurses?” and the comments on our posting last week bear that out.  Mr Brown’s Commission on Nursing and Midwifery hasn’t grasped this nettle.

Perhaps it is unfair to say that the six paragraphs of its recommended “nursing and midwifery pledge to deliver high quality care” can’t compete in the prose stakes with the Hippocratic Oath.  But then even the most uplifting sentiments are never going to stop more  Harold Shipmans, Bristol  heart baby surgery cover ups or Stafford Hospital scandals on their own.  Ensuring patient safety, dignity and respect aren’t about taking a pledge, they are about changing a culture.

Health care staff – nurses in particular as the most numerous and omnipresent group in the workforce in contact with patients and carers – should simply do the job of delivering quality, patient-sensitive, effective care they have been employed to deliver.  If the environment or resources prejudice quality care, then they must say so quickly, clearly and loudly.  That’s what the public has a right to expect.  It’s not as if we don’t know what excellent care is like:  Essence of Care, a tool  to benchmark the delivery of high quality care by nurses was published in 2001. Its relevance has never been greater.

Leadership and management first please

The Commission’s chair, former nurse and now Health Minister, Ann Keen MP, wrote in the introduction, “Truly compassionate care is skilled, competent, value-based care that respects individual dignity. Its delivery requires the highest levels of skill and professionalism. Tackling poor practice, however, is not solely the responsibility of individual nurses and midwives. Significant improvements are needed in many of the organizations and teams in which they work.” Of course, but that’s rather stating the obvious. The hard question is how to ensure that this is the care that is actually delivered by every nurse, everywhere.   The answer to that is about leadership and management, not compassion.  This is one reason why the current discussion about a “John Lewis approach” to public services is so interesting.

200,000 nurses to retire

We can’t sit around waiting for an answer.  Recent research concludes that 200,000 nurses are due to retire in next decade.  There will never be the young people to replace them.  We knew that very well back in the 1980s when I worked with Harry Judge on the RCN’s Commission on Nursing Education review.

Getting more mature people and career changers into nursing are fine strategies, but will never be enough to make up the numbers.  Our understanding of what “a nurse” is must change to reflect this reduced availability.  There must be more skill mix in caring teams across health and social care.  In the context of our ageing and increasingly diverse population in the UK, we must rethink a key question: “what is nursing for?”

It’s about outcomes, as always

British society isn’t clear – and the Commission on Nursing and Midwifery doesn’t help on this point – about the outcomes we as current and potential health care customers need and want from modern nurses.  This must precede the creation of a  process of professional formation to educate, regulate and support people to deliver these outcomes.

In other words, think about the ends of nursing first, then the means to deliver them will be clearer.  We might be surprised at the answers.

Practitioners not tribes

The ends of  health and social care have to be deliverable by a flexible and confident workforce with the right skill set and motivation.  Just as healthcare consumers want one stop shops – though we rarely get them – so we need more access to  multiskilled practitioners particularly in primary care.  Models that work in developing countries should be tried in our inner cities and rural areas. As health inequalities widen, we have nothing to lose.

We need public health practitioners who can specialise in maternity and early years; children and schools; older adults; special needs; long term conditions in community and primary care settings, and also mental health.  These practitioners must be degree level prepared and – crucially – have vocational competencies  (N/SVQs at and beyond level 4/5).  This is a challenge higher education has to address for professional education generally.  Just having a degree isn’t enough to ensure safe practice.

Making the current health care “tribes” better at what they do (nurses, doctors, therapists etc) doesn’t address the real need for the future.  To do that, we must have practitioners from whatever discipline who can deal with undifferentiated and undiagnosed conditions and respond accordingly, prescribing being only one of the more obvious ways to respond, and manage long term conditions and most other care outside of hospitals.

Consumers want deliverables not declarations

From a consumer point of view, these are the contentious issues that the Prime Minister’s Commission should have grappled with if  it really wanted to move nursing to centre stage as the 21st century’s primary user-focused service.   It unsettles many professionals to admit it, but consumers must come first because we are the people who pay for and use the service and this confers ownership.

What this means in governance terms is still largely un-examined in the NHS (and public services generally).  MAC is about to publish our thoughts about “Whose NHS Is It Anyway?”, so watch this space.

Making the practitioners better at what they do now (pledges, oaths and declarations not withstanding) can’t be neglected, but on its own it will not deliver a whole solution.  Before we know it, we shall be back with yet another Commission before the pages have even begun to curl on the report of the present one.

We can, and must, do better.

No progress without parents

Booked your holiday yet?

If you have children in school you may want to cancel your plans and set aside some quality time to be involved in a quick consultation this August.  This week the Conservative Party announced that if they get into power after the next election they will pass legislation which will allow many schools to become Academies by September of this year.  Talk about hitting the ground running!  “Unless we act now our children will lose out in the global race for knowledge.” panted Michael Gove hotfoot from the glassy classrooms of Mossbourne Academy in Hackney.

Sometimes it feels as if, in the quest for education reform, we and our children have got caught up in a the great caucus race in Alice’s Adventures in Wonderland.  You remember:  all participants have to run in circles until  an arbitrary end is called and everyone is declared a winner; Alice has to give prizes to them all, and being declared a winner too she is solemnly awarded back her own thimble.  Sounds like the way education reforms work to me!

If they win the election Mr Gove expects a new Education Act to become law by the end of July.  Stop and catch your breath Michael.   Didn’t you say something a few weeks ago about the importance of involving parents in decision-making in schools?  I assume you would want them to be involved in a decision which will “free” their child’s schools from “political control” and allow them to” take over” other schools not to mention totally change their governance and accountability arrangements.  I trust you will be following the widely recognised good practice guidelines for public consultation: twelve weeks minimum and ideally not over a holiday period.  Mmmm, not sure 31 days in August (including a bank holiday) quite fits the bill but  I know heads and governors are always looking for more to do in the summer holidays.

Progressive or just depressing?

So if this is what the Conservatives are planning to do to help our benighted children keep up to speed in the global race, what are other lot up to? February saw the launch of the Progressive Education Network with a suitably schooly presentation at the House of Commons: many, many teachers sitting neatly in rows – a few recalcitrant trouble-makers chatting at the back – while a string of other teachers (and teachers turned politicians – eek!) demonstrated their enthusiasm for our schools as they are.  Their launch document set out their stall:  ”It is our conviction that what is needed now is to deepen the partnership between schools, government and local communities, not to put it aside and replace it with a complete change of direction.”

It is good to know that politicians and teachers are kissing and making up (or at least some of them are) but I can’t help thinking they don’t really want “local communities” or parents anywhere near this special relationship.  In the first forty-five minutes of this inaugural meeting the word “parent” was not mentioned.  A quick speed read of the 12 page closely- typed manifesto revealed that the”P” word did not appear once so I grabbed the mike and asked them where parents were in their thinking.  The bad boys at the back pricked up their ears ready for a fight – but it was not to be.  There was much nodding and smiling at me and some thinly veiled irritation that a parent had found her way past security and into the staffroom.  I don’t know if they had been forwarned that one of us (Them?) had got in but the party line seemed to be that schools were now terribly good at involving parents – we only had to look at the Building Schools for the Future programme to see just how good.  Then they went back to talking about how much schools and teachers are valued by their communities.  It was tempting to ask them how they knew but I think I might have been given a detention.

It is depressing to see that something proudly calling itself “progressive” should be so unthinkingly reinforcing the outdated notion that public services should continue to be controlled by politicians and professionals even in the face of increasing evidence that educational attainment depends more than anything else on getting families involved in their children’s lives at school.  The recent Marmot Strategic Review of Health Inequalities Post 2010, states that “evidence on the most important factors influencing educational attainment suggest that it is families, rather than schools that have the most influence.  Closer links between schools, the family and local communities are needed”.   Certainly we need to find the right  balance between politicians and professionals but there is a third leg to this stool that schools ignore at their peril.

It is great if it really is the case that “communities” (students, parents and local people) are being allowed to have a say in what their new school buildings look like but this matters far less than how they get involved in what goes on inside those buildings and what their children bring with them when they come home.

A consultation post-script

A fourteen year old child I know well was recently asked, as part of a school-wide exercise,  to come up with a name for their new dining room (recently built as part of Building Schools for the Future).  Here is her response:

Suggested name for the dining hall:  ”Dining Hall”

Reason for suggesting the name:  ”So people know what it is and don’t get confused looking for a place with a silly name.  Everyone will call it the dining hall anyway”.

I doubt she will be winning the £50 voucher but look forward nonetheless to hearing the outcome of this particular consultation exercise.

Will John Lewis-style partnerships work in the public sector?

Andrew McMillan is the best placed person I know to comment on the John Lewis ethic from the inside because until recently as he mentions in his piece, he worked for them and has seen the reality from the inside. The question we asked him was ‘can this approach really be transferred to the public sector?’ Read on for his answer

The Government’s plans to consider transforming public sector bodies into John Lewis-style partnerships if it wins the next election could bring public sector employees the benefits John Lewis’s staff enjoy, including a powerful collaborative spirit among staff; staff having much more control over their own direction and purpose; and a serious and significant commitment to customer service.

I worked for John Lewis for 28 years in a variety of managerial roles, and can testify that the partnership spirit at John Lewis is infectious and energising. There is a strong sense of community there and of belonging, a powerful sense of ownership, and a feeling that everyone is pulling together. People who meet while working at John Lewis often become friends for life and this brings with it feelings of self-esteem and of self-worth, as well as an eagerness to apply oneself to meeting and – ideally, of course, exceeding – commercial imperatives, as their market-leading trading results last Christmas demonstrated.

Who, ultimately, are the prime beneficiaries of this spirit of partnership and collaborative work? Certainly the staff of John Lewis benefit from it, and not only in the annual distribution of the shared bonus in March, which usually equates to about six to eight weeks’ salary.

But the biggest beneficiaries of all are the customers, who benefit from a long-term approach to business and customer service, where thinking isn’t confined to what can be sold to customers today. Instead, there is a genuine sense of caring for customers, who are treated as individuals, not merely viewed en masse as a source of revenue. There is a feeling of wanting to do the right thing for the customer, even – on occasion – if this is not in John Lewis’s immediate commercial interests.

The potential benefits to customers of public sector organisations being run according to the John Lewis model are very tangible, and harmonise with Government aims to make customers absolutely central to the running of these organisations. Unfortunately, despite what the Government says it would like, many public sector bodies can be dominated by their internal metrics and administration rather than doing what is best for the customer.

Yet many of the key attributes to deliver a John Lewis culture in the public sector are already in place. Many of the individuals I have worked with in Local Government and Health quite rightly regard themselves as having a vocation. The truth is that the public sector has far more dedicated and devoted people working within it than the media seems to realise, or is willing to accept. It could be argued that the adoption of the John Lewis approach would actually make it easier for the Government to tap into employees’ vocational spirit.

So what needs to change? John Lewis has a great focus on simplicity – making it as easy as possible for front line employees to concentrate on looking after their customers – whereas the public sector often has complex and time consuming administration procedures that take people away from the very thing they joined to do – serving the public. Of course there are many statutory requirements in the public sector that are in place for a good reason and have to be met. But equally many of the processes and procedures in the public sector are there to serve internal systems and can be simplified or eliminated all together. Taking this approach can also save huge amounts of revenue, so creating a win-win situation – the customers benefit from better service while the organisation can save a substantial amount of budget which, of course, is another key imperative in the current climate.

The other major difference I have observed is the opportunity for managers in the public sector to really lead their teams rather than manage their activity. It sounds obvious, but one of the key focuses at John Lewis is to encourage inspirational leadership and this means creating the opportunity for managers to spend time amongst their teams supporting and coaching them to deliver defined goals. Again, I have met many public sector managers who wholly embrace this concept, but find themselves locked in their offices managing the vast amount of administration their teams are encouraged to create. This makes sustained change almost impossible and, if not resolved, will make any significant transformation of the public sector impossible. Of course, there are some employees in the public sector who would not be able to rise to this opportunity if it was available, but in my experience that is a fairly small minority. I have witnessed some remarkable change within the public sector clients I have worked with when the managers and employees are allowed to return to the principles that attracted them to work in the sector in the first place.

If the initiative to give public sector bodies a partnership structure is to succeed, the Government will have to overcome some significant challenges, such as creating even more of a focus around delivering results and positive change through embracing the concepts of simplification and leadership as opposed to management. I have seen this achieved with some outstanding results at a local level, but it would be so much more powerful if it were to become part of the central Government agenda. The effort and energy required by such a transformation would be worth it, and – make no mistake – customers will benefit significantly.

Andrew McMillan is a principal consultant with business and information technology consultancy Charteris plc, with much of his recent work being in Local Regional Government and the National Health Service. Previously to this he worked for the John Lewis Partnership for 28 years. During his final eight years there he was responsible for customer service across all John Lewis UK department stores.

Additional Information:
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Email Andrew.McMillan@charteris.com
Tel: 020 7600 9199

March MAC Blog Round-up

The ways things are organised was the February theme of the month with MAC Partners writing about organisations which have failed and those which are held up to us as model enterprises. Can we associate a particular form of organisation or the way that it is governed with a higher probability of success? We asked in our piece prompted by the political popularity of the John Lewis model “will the new emphasis on mutualism or participative management work? MAC Partners will be giving their views on this in the context of schools, NHS institutions and approaches to governance and we are hoping from a contribution from a long-time JL employee as well”.

Not Just Theoretical

This is not just an academic question as at least 400 – and some say 1200 – people died at the Stafford Hospital part of the Mid Staffordshire NHS Foundation Trust between 2005 and 2009. Andrew Craig says that the subsequent Francis enquiry is not strong enough on improving Foundation Trust governance. He wrote

“It largely ignores the role of the Trust’s owners – the Members of the Foundation Trust and their elected Governors.   A Foundation Trust is after all defined in law as a “public benefit corporation” – a species of social enterprise -  but what that means in practice has been deliberately fudged by Ministers and Monitor since FTs were first created. Now we can see what that sort of “governance neglect” can lead to.  Francis could have made a big stride forward to rectify that, but instead it made a rather bland recommendation to empower members and governors.  Much, much more needs to be done about ensuring there are stronger public and service user Governors and – crucially – about empowering staff governors elected from the Trust’s own workforce.”

There were others working within the organisation who could have spoken out – where were the nurses? asks Andrew. “They are everywhere and they see everything.”

‘How was it for you?’ – Consumer Focus Asks the Question

The racily post-coital title ‘How was it for you?’ may help draw attention to the Consumer Focus report on the consultation done by Post Office Ltd (POL) on the closure of post offices. We need this sort of evaluation although the findings can be very depressing since the same mistakes are made time and time again. However the findings do identify two core causes for the failures of consultations.

No room for emotions

The first is the failure to recognise the emotional drivers that lie behind the public response. The 2.7 million people who responded in Consumer Focus’s reckoning to the consultation were prompted very often by a ’strong emotional attachment in keeping post office branches open’ . They also believed that the consultation was about whether post offices should be shut. The grey men of POL were focused by contrast on which post offices were to shut since the business case made it clear some had to go. Their approach took no account of the public’s feelings and ignored representations on the wider issues. This mismatch increases the public cynicism with consultation seen as a sham.

Some views more interesting than others?

POL also shot itself in the foot by doing some consultation amongst consumer bodies and others before going out to the public. Between times they had reacted to the comments made in the earlier round so giving the public less to get their teeth into. Guess what? Refer to above: consultation seen as sham. The consumer organisations have to involve themselves  in working out a solution for this – they enjoy being acknowledged as a port of call for reasoned and useful reactions to initiatives like these. But if it risks them being seen as being part of a process that excludes the public they purport to represent, they risk betraying their own rationale and purpose.

Angry and Stuck? Move on with the MAC solution to the US Healthcare dilemma

Accusations of betrayal and sell out would appear to be some of the milder epithets to be heard in the great US healthcare debate. Andrew Craig reports after a recent US trip that the issue is unavoidable being piped to every departure gate in every American airport for every flight of the day. And yet he points out the US already has a National Health Service of sorts. The US National Health Service Corps, part of the Surgeon General’s Department,  aims to have over 8,000 primary care clinicians caring for some 9m Americans by 2011.  Since 1972 National Health Service Corps primary care doctors, dentists, nurse practitioners, nurse midwives, physician assistants, dental hygienists, pharmacists, therapists , mental health professionals and others have mainly worked in small towns, isolated rural areas and deprived communities of all sorts across the US where accessible or affordable health resources are scarce. The American NHS Corps is a reasonable and well-established model of grass roots primary care. It could be generalised across the country.” Why not start with what you have already got? Andrew asks President Obama. If he replies, we will let you know.

In the meantime, we have a situation of politically pumped up public emotion where the din of debate drowns out the arguments. Tricky stuff dealing with citizens, users and others of that ilk.

Always eager to hear your views and we hope you enjoy this summary and the individual blogs themselves.

Stronger and more accountable Foundation Trusts needed to avoid “Staffordshire 2”

At least 400 died needlessly

“These patients were not simply numbers: they were husbands, wives, sons, daughters, fathers, mothers, grandparents. They were people who entered Stafford Hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives.”

The enquiry was published this week on deaths at the Stafford Hospital part of the Mid Staffordshire NHS Foundation Trust between 2005 and 2009.   It should be required reading – all 455 pages of it -  for commissioners and Trust board members everywhere. What happened in Staffordshire could happen elsewhere unless governance and clinical behaviour are drastically improved.

Don’t just read the recommendations or you will miss the outrage you should feel at the recurring catalogue of systemic clinical, governance and above all individual failings (nurses but also doctors and managers) that resulted in the untimely deaths of some 400 people (maybe up to 1200 according to some accounts).  If a train crash killed 400 people, there would be an immediate public enquiry and Ministers would be front and centre.  But that’s not what happened here.

No openness: no challenge: no change

The Francis enquiry report  is not strong enough on improving Foundation Trust governance. It largely ignores the role of the Trust’s owners – the Members of the Foundation Trust and their elected Governors.   A Foundation Trust is after all defined in law as a “public benefit corporation” – a species of social enterprise -  but what that means in practice has been deliberately fudged by Ministers and Monitor since FTs were first created. Now we can see what that sort of “governance neglect” can lead to.  Francis could have made a big stride forward to rectify that, but instead it made a rather bland recommendation to empower members and governors.  Much, much more needs to be done about ensuring there are stronger public and service user Governors and – crucially – about empowering staff governors elected from the Trust’s own workforce.

Then there is the role of the Local Involvement Network (LINk).  Why was there not a functioning LINk locally?  Why were there no unannounced visits to these wards under enter and view powers and reports made to the local authority and the PCT about obvious care shortcomings?  I cannot image a Community Health Council (CHC) pre their abolition in 2003 failing to respond vocally to the first reports of failing standards.  This is a measure of what we have lost in local accountability.

Closed enquiry

In Staffordshire theenquiry led by Robert Francis QC was closed and so most members of the public and the media outside the region were not even aware of until it reported this week.   To its credit the Francis team produced a good report, concluding that patients were routinely neglected by a Trust that was preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care in a headlong pursuit for Foundation Trust status which it achieved in January 2008.

But however good its recommendations, this process isn’t the same as a robust enquiry held in the public and media eye and it falls far short of assigning responsibility for these failings to individuals.  Only individuals can be held to account for this magnitude of institutional failure.  Think casino investment banks.   The Trust as a corporate body and its culture are only the reflection of the sum of the behaviours and attitudes of the people who comprise it -  the clinical staff, managers and board members in particular.  Some of them did try to raise the alarm, but most did not.  Some were cowed into silence, but it seems that most chose to look the other way. Or maybe they just could not believe it was happening to them.

Where were the nurses?

Most worrying of all is the question “where was the voice of professional nursing as the patients’ champion?”  The Trust’s diverse nursing team are the most numerous group of employees and always will be. They are  everywhere and they see everything.  Had nurses taken a united stand and made their collective voice heard, the care failings of the Trust would have come to light much earlier. Where were the letters to MPs that the hundreds of nurses working in this hospital should have written?  Where were the local nursing clinical leaders? Where were the nursing trade unions and professional bodies?

Does the buck stop nowhere?

If people knew and did nothing, that must be culpable if not criminal.   If some senior people at the Trust are not personally held to account for this, then the message is “the buck stops nowhere” and accountability is reduced to a cipher.   Relatives are demanding responsibility at this level and so too should the public because this outrage took place at a time when the NHS has never been more regulated and this Foundation Trust was – on paper – rated a good, and safe, provider of services.   But no one challenged the failures.

Governance matters

The enquiry recommendations could have clarified that the governance of the Foundation Trust must be rooted in the membership community and its elected representatives whose role is to hold the Board to account and who must be supported to carry out that role.   This seems to be what the Secretary of State Andy Burnham is now talking about in his reported views about strengthening the Governors of FTs .  Will he translate these words into action?

This Foundation Trust’s board meetings were held in private.  That was wrong and Mr Burnham has now declared in a parliamentary answer that FT Boards must meet in public and Governors must have access to all Board papers. There is still some wiggle room in that which needs clarifying.  It is welcome, but in itself it will not solve the problem of a culture opposed to openness and challenge.

It is an indictment that without the persistence of “Cure the NHS” -  a local group of patients and relatives who knew that things were going wrong within the hospital, who raised complaints and whose members kept shouting despite efforts to silence them –  the magnitude of this scandal would never have come to light.  Their contribution is praiseworthy, but they should not have had to make it alone.  The Foundation Trust is after all “owned” by its Members who elect a Council of Governors to hold the directors of the business (the Board) to account for delivering safe, effective services and fulfilling their strategic plan.

Stronger Governors needed now

Should FT Governors therefore have a role in the complaints process?  That is one option raised by Francis, along with the possibility of the Governors electing their own chair instead of sharing a Chair with the Board as currently.  Both suggestions have merit and need serious consideration. Governors could be effective scrutineers of the complaints process (which could do with improving its performance in many Trusts), but should not as individuals get directly involved in complaints handling.  And Governors deserve their own, independent chair.  Having the same person chair the Board and the Governors invites conflicts of interest as was obviously the case in Staffordshire.

FTs at a crossroads

The Mid Staffordshire scandal shows Foundation Trusts at a crossroads. We must learn from this and quickly because all other NHS Trusts are headed for Foundation status or else franchising from an existing FT.   These “community benefit corporations” must be made to behave for the benefit of the community and be accountable to its representatives.  They  must be directed by Government down the road of greater local accountable to their Membership communities through stronger, more effective Governors – public and staff.  If this does not happen, then it is just a question of waiting for “Staffordshire 2” to happen.

Dear President Obama, build US healthcare on what works already

No Place to Hide from Healthcare Debate

In between dodging blizzards and snowdrifts flying around the US from coast to coast for three weeks earlier this month for work and to see friends and family, there were lots of opportunities to soak up what the media and individuals were saying about the debate  on health care proposals from the US Congress and the Obama administration.   Actually you couldn’t avoid it if you tried.  CNN, FOX, MSNBC and all the rest of the rolling news services are pumped into all airport gate waiting areas and there is no escape as it seeps repetitiously into the brain.   To say there was no consensus in the broadcast media is putting a polite European gloss on what is without doubt an increasingly strident and partisan political shambles for which the prognosis is poor unless something is done to reverse it quickly.   The tragedy is that it doesn’t have to be like that because the US has elements of a healthcare system that are reasonable building blocks on which to construct something much better.

Remember Rule Number One

I came away from our three week jaunt across America convinced – and rather saddened given the scale of the obvious unmet need for primary healthcare in particular – that the US debate started in the wrong place.  I have some sympathy with those –  the majority? – who say the are confused at best by the competing proposals and anxious that they might lose something which – if they are lucky enough to be employed and live in the right place – just might entitle them to  a reasonable service (though at a high cost).

I was reminded of my “Rule Number One” in health promotion  – you have to start with where people are if you want to enable them to move to another place.   Sadly – and due in no small measure to the mega bucks of ubiquitous lobbyists in Congress -  government figures seem intent on creating a highly complex debate which ordinary people out on Main Street USA simply cannot follow and therefore distrust.  Which is when the shouting, demonising and teabagging really starts to ramp up.  Judging from the National Tea Party Convention in Nashville last week, these people are just getting into gear with their volatile alienation from conventional politics.

Build on what’s in place already

Most Americans, to my surprise, are not aware that the United States already has a National Health Service of sorts.  The US National Health Service Corps, part of the Surgeon General’s Department,  aims to have over 8,000 primary care clinicians caring for some 9m Americans by 2011.  Since 1972 National Health Service Corps primary care doctors, dentists, nurse practitioners, nurse midwives, physician assistants, dental hygienists, pharmacists, therapists , mental health professionals and others have mainly worked in small towns, isolated rural areas and deprived communities of all sorts across the US where accessible or affordable health resources are scarce.

The American NHS Corps is a reasonable and well-established model of grass roots primary care. It could be generalised across the country. Primary care is in dire shape in many places and GPs as we know them are beyond being an endangered species.   To the NHS Corps could be added the hospital and rehabilitation services of the extensive, and recently much improved in terms of quality and safety, Veterans Health Administration health system.  Beyond that, of course, are the mega bureaucracies of Medicare (for the over 65s) and Medicaid (means-tested for low income groups) which provide ample learning of how to – and sometimes how not to – run comprehensive(ish) single payer, insurance-based, mass coverage programmes.  No one is arguing that these programmes as they exist now are fit for purpose for a country-wide unified health service.  But they are generalisable and capable of considerable improvement.  Most importantly, they were invented in the US and well-understood in the American political context.

Taken together the NHS Corps, Veterans Administration, Medicare and Medicaid could form a large nucleus  of publicly funded healthcare services around which pragmatic politicians could weld a system of single-payer, universal access health care.  And they could start with primary care which is in such short supply in most locations and which – as we know in Europe – is the key to grappling with the manifold problems and costs of the acute sector.   So why isn’t this happening?

Keep it simple stupid

This motto ought to hang by law on the office wall of all Members of Congress and every room in the White House.  Healthcare reform and complexity are a lethal mixture.  The title of this week’s online editorial in the New England Journal of Medicine sums it up: “the complexity that killed health care reform (again)” Just as with the Clintons’ ill-fated attempt at healthcare reform in the 1990s, history seems to be repeating itself.  President Obama and the drafting committees in Congress have reached too far and tried to accomplish too much all at once, ending up pleasing no one and leaving the “debate” wallowing in a slough of complexity.  The healthcare bills emerging from Congress are themselves strictly for chronic insomniacs and legislative masochists — 1990 double-spaced pages for the House bill and 615 pages for the Senate bill.  President Obama has yet to produce his version – and the big question is why did he let slip such an opportunity to capture the heights of the healthcare agenda? Let’s hope it’s a snappier read when it does appear.

Remember Rule Number Two

My “Rule Number Two” in health promotion-  don’t let striving for the best get in the way of achieving the merely good – applies to the US dilemma about healthcare reform in a big way.  Specific provisions, passed by Congress one by one if necessary, should be used to create a new, comprehensive system by welding the existing parts together with general principles.  An omnibus leviathan piece of legislation to do everything at once will not pass (as the Clintons should have realised).   That way ends up pleasing no one and plays into the hands of the (many) enemies of publicly funded care.  The devil is in the detail remember.

What is happening this time is doubly sad.  The current proposals actually seem to alienate many of the very people who would benefit.  Perhaps this is understandable in a time of recession, foreclosures, fear of higher taxes and job losses.   Starting to build on what already exists, therefore, would be a better (because less threatening) tactic and “keep it simple” should guide the legislative output.   Primary care has to be the right starting point.  Get that right – as we know from struggling with the issues around the NHS in Britain – and everything else will fall into place.

I wondered in all of this what Americans who use the NHS Corps services think about them and are they involved with planning them?  That’s something I would really like to know more about if any readers of this blog can point me towards some evidence of user engagement with them. It will be interesting to see what emerges from a research project by Involve and Consumer Focus seeking to quantify the benefits of public engagement.  A post on the Public Decisions blog in the US from Involve in the UK announces an ambitious project with Consumer Focus England. The project is seeking to develop an equation for identifying costs and benefits associated with public engagement structures and processes and is asking for examples from the US.

The world according to John Lewis

Suddenly the John Lewis Partnership is the flavour of the month with both the main political parties pushing mutualism and the principles of the co-operative as the way to go when it comes to delivering better quality service and goods.Waitrose has come top two years running as the Which? subscribers favourite shop with John Lewis second in the latest poll.

Lambeth we are told is to become the ‘John Lewis Council’ where residents and staff working together will transform service and  participating council tax payers can look forward to financial benefits. I have my fingers tightly crossed in the hope that this idea holds good as the leaseholders of my block of flats head down the self-management route in the belief that we can do a better job. The principles of public engagement and participation are being refocused on a model of co-management.

Forms of ownership and benefits thereof

The case that certain forms of ownership lead to better results for customers has always been fiercely debated. Those in favour of the co-operative model can point to the fact that recently the Economist reported that the only bank in the world with a AAA rating is Rabobank a Dutch co-operative bank focused on agricultural lending. It has not strayed from those roots (sorry). The 1200 co-operative banks in Germany also enjoy good credit ratings with no banks of this sort filing for bankruptcy in 75 years.The problem comes, the Economist pointed out, when they stray from the conservative policies of the past in favour of a fling with flashier and more fun adventures in investment banking. Mutual management did not stop these ill-advised excursions.

Excellence Unconfined to Mutual Model

As it happens the same issue of the Economist – have I been spending too much time in airports? – noted the knighthood of Fazle Hasan Abed an ex-accountant from Shell as recognition of his role as the man who built BRAC – the world’s most commercially-minded and successful NGOs with a microfinance operation that disburses about $1billion a year. A book on BRAC by Ian Smillie described ‘the spread of its work dwarfs any other private, government or non-profit enterprise in its impact on development’. Another writer called it ‘ as near to a pure example of a learning organisation as one is likely to find’. This NGO is run as a business and a very successful one which certainly has social goals but these goals do not determine the governance of the organisation.

So will the new emphasis on mutualism or participative management work? MAC Partners will be giving their views on this in the context of schools, NHS institutions and approaches to governance and we are hoping from a contribution from a long-time JL employee as well. Why doesn’t the Co-op rule the world? Is John Lewis a more likely candidate?

Closed but not forgotten – a postmortem on the Post Office closure consultation

It is not often that people take the time to look back at a consultation and ask themselves the question ‘how did we do?’ After all, why bother? Though the dog may bark the caravan  moves on. Policy gets made or not and the issue dealt with after a fashion or left alone for another day, ‘kicked into touch’ as they say adding for good measure that ‘the money has gone anyway’ and we all move on to the next issue.

So we welcome Consumer Focus issuing a  report in February with the racily post-coital title ‘How was it for you?’ on what they considered the main lessons to be learnt. It was encouraging to see their research suggesting that 2.7 million consumers made their views known. People do join in when they think the issue is important. Depressingly, their evidence showed that communications were treated by the Post Office as a ‘necessary evil’. Consumers and local bodies were not briefed on the best means to channel their representations – local petitions and signature drives were discounted in favour of more formal submissions.

Consumer views were often cynical – a voice from Dumfries is quoted “It’s a sham – the consultation process you know: ‘what are your views, thanks very much, we are closing it anyway’. …they listened to no-one because they had already made their mind up”. The Post Office failed to make clear – or perhaps people did not want to hear – the fact that the consultation was not about whether post offices were going to be closed but which ones were to be included in the 2500 target figure.

Of particular interest to us as professional advisers on how to do this sort of thing, was the situation where what seems good practice in fact had a negative effect. There was an eleven week period of pre-consultation when POL (Post Office Ltd) sought the views of local authorities and the established consumer bodies and took on board what they said, changing over 240 of their original proposals. But this meant that the scope for change as a result of what ‘ordinary’ consumers said was limited. This added to the consumer perception that all the big decisions had already been taken.

This is an issue where the consumer organisations have to be as involved in finding a solution as the body doing the consulting. They were party to this closed process and need to play a role in explaining what went on and why they took the line they did. The risk they have to face is that ‘ordinary’ consumers do not like what was done on their behalf.

The emotional reaction to programmes of this kind where the public perceive parts of the national life under threat is very difficult to manage and give due weight to in any consultation exercise. POL thinks it is consulting about closing some shops and relocating some services – no big deal. The public saw what Consumer Focus called their ’strong emotional attachment in keeping post office branches open’ as a totemic issue. In these circumstances our experience suggests the strength of the views expressed owe little to any recent or regular experience of the service in question. Very different starting points that demand different techniques to bring to any sort of satisfactory resolution.

The Consultation Institute’s Consultation Charter has a go at summarising best practice in this area, echoing many of the Consumer Focus recommendations.

NHS User Action Research – Choosing, Booking, Sampling and Giving

The headline says it all really. Log in and choose the appointment and wait while it whirrs away and does it. All very simple and hi-tec. But not the whole process – my referring GP wrote the details down in a big notebook first and the paper work reached me about 5 days later. Some productivity gains yet to be made.

Some concerned blog readers contacted me  as a result of my mentioning the bowel cancer test. Thank you for your concern but no need to worry – it was just a screening test programme and the results were fine. I just wonder what the take up is like on this particular exercise. Collecting the sample challenged both motor and organisational skills and doing it all involved confronting certain of my own (and most other people’s I would guess) established personal behaviours and attitudes. Is there a medal to be awarded?

The next participative saga involving the gift of my state of being and medical history as the NHS UK BioBank project tracks me to my grave is yet to come – watch this space.

Getting My Sh*t together and other belated New Year resolutions

Faecal occult blood has a certain fashionably vampire ring about it. It gives the right air of spooky mystery so encouraging us all to get engaged and involved in our own health by sending in our samples for the bowel cancer screening programme. The instructions for collection are admirably brisk and matter of fact and we need not go into the detail here – the main point to remember is not to put the cardboard sticks down the loo. The collected goodies are then to be consigned to the post where we must hope there will be no recurrence of industrial action and postal delays. Anyway resolution one – to take more interest in my health – is  being put into practice although it may take a moment to get beyond the instructions in the leaflet. (Sound choice of communication channel – not one for You Tube.)

So I was already  in the right engagement frame of mind when a couple of days later I got an ‘invitation’ to join  the UK Biobank research project inviting me to come and be what – cloned in Croydon? Well something is happening in Croydon that  the distinguished researchers signing the letter assure me that while it will not help me directly, future generations will benefit from the data gained from tracking me and my health (are they separable?) into my grave.  This is one – positive – demonstration of how electronic health records make our addresses available to the passing researcher. They even offer to pay parking and travel expenses.

Add to this, the Tribunal action with other residents of my block of flats and the cup of public involvement rather over-runneth. But I and the other MAC Partners busy contributing as parents, members of the friends of the local park or in the GP practice patients group, do find that active engagement means that any advice we may offer others on how to engage people is all the better for having seen it from different perspectives – researcher, organiser, participant.

This gives us lots of stuff we can blog about on our new and improved website. We have brought together the public involvement blog and the main site and given it a new and lively look. We hope you enjoy it and feel free to give us some comments on how it looks and feels for you.

There have been a couple of blogs already this year. What do you think of the NHS Constitution? We give our views. The other blog is an inspired piece of photo journalism showing how a Kenyan hospital near Mombasa goes about getting its vision and service commitments across – they have not yet embraced the label ‘Constitution’.

2010 is looking good already and Partners enjoyed a Chieftain Haggis from MacSweens of Edinburgh. And if you thought Chieftain was the name of a tank, take another look at both haggis and monster vehicle and wonder which was named after the other. Memo to self – engage in own health and eat fewer tanks in 2010.

Belated though our resolutions may be as this letter emerges at the beginning of February, that does mean that they were not forgotten by 2nd January. To all our readers working on their 2010 plan, we hope that your resolutions are similarly durable and do not vanish like snow off a dyke.

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