Quick, make more leaders

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As a GP for more than 30 years I have seen the same promises and aspirations for the NHS cycled and re-cycled. “Put General Practice in control”, and “We will shift activity from hospitals into primary care” successive Ministers of Health, have shouted from the front pages of the tabloids. They have given us Fund Holding, Primary Care Groups, Primary Care Trusts, CCGs and nothing has changed. Now we have Primary Care Networks (PCNs)- why are they going to be different?Well of course they are not, unless something is done differently. To understand why that is, we have to understand why all these changes of the past have not achieved their promise. This short blog tries to explain why this has happened, how putting it right isn’t that difficult and suggests a model the NHS could adopt to get where it needs to be.

A significant problem is that the NHS is an autocracy with layers of hierarchy, a consequence of which is that it tends to serve the leader rather than the people. All its leaders have trained within hierarchical systems and learned management processes that have been refined through manufacturing industries: like Toyota’s ‘lean’. When it doesn’t work the NHS responds by trying to build more leaders. The NHS fails to recognise that it doesn’t need more leaders it just needs to lead in a different way, because healthcare is neither a manufacturing industry nor is it a Tesco, as Matt Hancock suggests: it is actually a complex adaptive system.

Have you read Team of Teams? Well, here’s a picture from it.

Team of Teams image

General Stanley McCrystal the author was the commander of Joint Special Operations Command (JSOC) in Iraq, who discarded a century of management wisdom and pivoted from a pursuit of mechanical efficiency to organic adaptability to get results in a chaotic system. He moved US armed forces from command and control to a ‘Team of Teams’. The NHS like his war-zone is complex adaptive system: it is inherently self-organising. There are no clear boundaries, there are multiple interdependencies between players and there is no clear locus of control yet it bubbles along continually on the edge of chaos. This means that when our ‘industry shaped leader’ touches a lever they don’t get what they expect. The finest movement, like the wings of a butterfly can make a hurricane, or a huge force may be dampened by unexpected inertia that dissipates all that effort.

Our existing NHS leaders are able to make the change they need but like a surgeon re-training to be a GP, there needs to be a fundamental readjustment to their use of knowledge.They need to start to adopt and espouse some of the techniques outlined by people such as McCrystal and move on to managing what is to become a team of Primary Care Networks. Fortunately the essence of this approach can be concentrated into a single sentence.

Here is that sentence.

To manage a complex adaptive system you need a clear destination, underpinned by common, agreed principles, with the right tools (infrastructure) on hand to facilitate it, then solutions will emerge across the system to move it towards its destination. Leaders are needed to set-up and stimulate that environment and like the sweepers in a game of curling, work like crazy, to smooth the way, to help the rocks slide towards the ‘house’. It may be difficult to see how this works in practice: here is an example for managing any chaotic Integrated Care System of Primary Care Networks.

The Destination:(the aim)

Let the people or patients or citizens set the objective. Let them describe their expectations from health and care services in their own voice and condense that into a succinct statement of their wishes. As we can all identify as patients this helps dissolve narrow organisational perspectives and the entire care system can adopt this unifying single destination. It might read something like this:

The people said:

“As a person I rely on all the parts our care system to function as if it is a single team with my best interests at its heart. I am confident that services will be there to support me to stay well and to help look after me when I am not. I know that no matter how complex or atypical my health problems are, my needs will not be ignored. I know too, that when my problems are common or minor, help for me will not be forgotten. The system that provides my care is open, transparent and always respects my autonomy. It demonstrates to me that it makes the best use of the tax I pay for healthcare in delivering the most effective, evidence based care, with the money available."

The Principles*:

By adhering to principles, autonomy in decision-making can be distributed across the system and leaders can be confident that the decisions that emerge from such collaboration will move us towards the destination set by the people we serve. Number 11 may be a game changer.

  1. Healthcare starts with self-care: from disease prevention to illness management, patients are supported to take personal responsibility for their healthcare at every point of contact with the care system
  2. The value that continuity of care brings in increased patient satisfaction, improved outcomes and cost savings, is considered in all care pathways and all services we develop
  3. Care is provided by the most cost-effective capable individual, and experts do what experts alone are able to do
  4. Care is provided as close to home as possible in the most appropriate healthcare facility
  5. Face to face contact is used where it offers additional value to the patient so that remote working is maximised to reduce stress on our environment and demand on our physical facilities
  6. All care outside of the hospital ward (including A&E and Outpatients) is considered community care and utilises a single electronic patient record
  7. Only those patients who need ward-based care are admitted to hospital and all other patients are managed and supported in an appropriate community environment
  8. Every member of our health community, whether employed in hospital or within primary care, can be reached directly by any colleague by phone or email using our digital directory to deliver ‘healthcare without walls’ in a single virtual health community
  9. We work collaboratively with our entire care community, including patient representatives, to develop and construct the care pathways and services that patients need and that the system can deliver, enabled by our collaboration portal
  10. All healthcare staff work within a culture of mutual trust and support, are valued equally across the healthcare system and derive respect and reward from their employment
  11. Our system *always seeks to work at optimum capacity*** and the cost of new treatment pathways and interventions are optimised and made publicly available


These are the tools that we need on hand to build the solutions to our problems and to move us forward together. You will likely identify more that are needed. In the italics are the organisations in my own health system (BNSSG) that I think are best placed to provide the tools that are required to get the job done, in other areas these may be different.

  1. Financial arrangements for money to flow in line with principles (CCG)
  2. Pathway development and modelling resources-people and software (CCG)
  3. Practice and PCN support services (GP federation)
  4. Single (cloud based) electronic patient record system for out of hospital care (GP federation)
  5. System wide (cloud based) extranet for individual and organisational communication (asynchronous) and collaboration (GP federation)
  6. Synchronous cloud-based, communication system voice, video and direct messaging with real time availability flag (GP federation)
  7. Technology enabled patient communication and support systems: digital first and digital second (GP federation)

Our Undertaking (From our Memorandum Of Understanding)

We the undersigned agree to work collaboratively and apply The Principles in all of the work we do in order to continually move towards putting in place a health care system in Bristol, North Somerset and South Gloucestershire that meets the vision for our health system described by the people we serve (The Destination)that we hereby agree as our shared, and unifying, objective.

So there it is, my attempt to write a Sustainability and Transformation Plan and to deliver a solution to all the ills of the NHS in 1300 words.

* The first 10 principles are taken from Healthcare Without Walls, the strategy for primary care from One Care BNSSG Ltd @onecaretweets

**Our system, rather than individual organisations, agree to produce the most it can of the desired output (product or service) with the smallest amount of cost.

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