12/11/2008 by Patrick Keady.

NHS Live has done it again! They promised lots. And then they’ve delivered so much more. Their latest outing, NHS Innovation Live, took place today at the Queen Elizabeth II Center, London.

Designed as a platform for sharing and celebrating some of the many achievements in today’s NHS, the event was hosted by Kathy Sykes, Professor of Sciences and Society at Bristol University and a Trustee of NESTA (National Endowment for Science, Technology and the Arts). Kathy has a knack for being in the right place at the right time. Not a stranger to the media, I like her balanced approach. Kathy is open to the people that she meets, while not loosing sight of the scientific rigour that she has been immersed in throughout her career.

Gill Hicks gave today’s keynote address. Gill lost both of her legs from below the knee on 7th July 2005. Gill told us about the hour or so that she was trapped in a London Underground carriage, her three cardiac arrests before she got to hospital, the make-shift stretcher used to get her there, the Paramedic who challenged discussions to pronounce Gill dead, the Consultant that told her ‘you will get better’, the nurse who got her to the hospital hairdresser just a week after the bombings, the cafeteria staff that chatted with her every morning, the physio who coached her back to her independence and the many other NHS staff that helped her through her recovery.

Interlaced with lots of humour about being Australian and some of the funnier experiences during her recovery, Gill held the mirror up to the 600 delegates at NHS Innovation Live. And what the delegates saw in the mirror, was a former NHS patient that was truly grateful for the services that the NHS provides. What they saw in the mirror was more than sufficient for many of the delegates that had travelled from near and far. And there was so much more to come.

They had many choices. Which two of the twelve breakout sessions would they attend. Did they want to learn how to release the innovator In themselves, or how social innovation can create a new model of health for men. Or maybe they wanted to know more about how Royal Bolton Hospital adopted LEAN Thinking. For the geeks, they could hear about generating and using patient stories to improve the NHS via Web 2.0 technology. Performance people could hear how an SHA is intelligently using information to the manage performance of its PCTs and Trusts. Other choices included how social and cultural background contributes to health beliefs and attitudes to mental distress, the excitement of setting up a social enterprise organization, how to nurture an idea and transform it into something really tangible and effective, exploring the role of charities and other third sector organisations in health innovation, using observation to find out what people do and how they carry out their work, improving understanding and the experience of patient and staff, and understanding mental illness from the perspective of service user.

Yet another excellent NHS Live event – well done to the NHS Live team. Why not sign up for their next event. Its free and they’re at www.nhslive.nhs.uk

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15/10/2008 by Patrick Keady.

I chaired NHS Risk Management today. Organised by the Health Service Journal, NHS Risk Management was their first conference that focussed exclusively on risk management.

Birmingham’s Centennial Centre was oozing with energy and attendees including clinical governance managers (10%), safety and health practitioners (15%), risk managers (35%) and directors (40%). And the delegates came from the full spectrum of healthcare organisations: SHA/other (5%), Foundation Trusts (10%), Independent Healthcare (20%), Trusts (30%) and PCTs (35%).

While I’ve been practicing in risk management for 20 years, I had mixed expectations of the conference …… and thankfully it was an enjoyable and informative conference. Here were some of the highlights for me.

Mark Burns, the Safety and Security Adviser at Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust reminded us of how risk management is now directly linked with Corporate Objectives. Trusts are more aware of their risk appetite - the level of risk that they are happy with. And he reflected on how reactions to incidents have improved – senior managers today ask ‘what happened?’ In the past, they would have asked ‘who did it?’

Linda Handley-Wright, the Risk Manager at Derby City PCT expanded on the theme of culture. The key is to make risk management interesting, using LEAN principles and engaging the right people. Linda added that organisations need to address different learning styles – including scenarios, what if’s and linking risk management with other initiatives via training needs analysis. In Derby, they’ve taken Standards for Better Health as the basis of something much better - they’ve produced the Healthy Derby 10-year plan aimed at improving health, commissioning and engagement.

And engagement was a key message from Dr Anne Dyas, a Consultant Microbiologist at Worcestershire Acute Hospitals NHS Trust. Dr Dyas urged that ‘we (people involved in managing risks) must get out there and teach. To be prepared to defend changes in practice with robust evidence’. She warned that changes introduced simply for public relations reasons will not be sustainable. Jobs done in haste will probably be done badly. Dr Dyas added that data is only as good as those that gather it – she warned against multiple data sources. Most extra tasks need extra hands and extra equipment. New initiatives must support the task (of infection prevention and control) and not add to it. And do Dr Dyas’s views work in practice? Definately. Dr Dyas’s team oversaw a significant reduction in MRSA and CDiff at their Trust and this helped them win the 2008 Oxoid Infection Control Team Award.

Anne Cleminson (Trust Secretary) and Steve Bradbury (Risk Manager) from Mersey Care NHS Trust described the key elements of Assurance at their Trust - getting buy-in from key stakeholders, Committees that are fit-for-purpose, an effective Assurance Framework and good communication. And the Trust’s biggest champions are the Non-Executive Directors because of their creativity and innovation.

Ian Strudley, Head of the Health and Social Care Services, Health and Safety Executive, reminded delegates that HSE is all about reducing the real risks – upto 250 people die every year at work in the UK and many more have serious injuries and ill health. HSE reduces the real risks, by balancing risks and benefits. He gave examples of how HSE is working in partnership with organisations such as the Healthcare Commission – agreeing the Concordat for joint working between regulatory and inspecting bodies. HSE works with the NHS Litigation Authority – workshops on stress management standards. And with respect to managing violence and aggression, it works with the NHS Counter Fraud and Security Management Service.

Stephen Williamson, the Corporate Health, Safety and Risk Adviser at University Hospital of South Manchester NHS Foundation Trust reminded us of what the ideal health and safety management system looks like - setting the policy, organizing, planning for action, measuring performance, auditing compliance and review. Steve reflected the views of many delegates with respect to NHS Patient Safety First – that it will succeed with Executive ownership, and clear commitment from clinicians, managers, corporate and support functions.

Gary Hay and David Firth, partners at Capsticks, gave an overview of key legal compliance and regulation. They described the risk-related legislation in place, CNST claims, the NHSLA risk management standards, employment legislation and stress at work. No real surprises there. And then they introduced a case-study about a patient scalded in a bath – and delegates faces lit up. The case study renewed the energy of the audience. The case study felt real and it gave the delegates and opportunity to contribute.

And then the controversial (and most thought-provoking) presentation – on World Class Commissioning. Controversial because it was close to home for many of the delegates. Roger Hymas from Humana, had recently completed a secondment as Director of Commissioning with Hampshire PCT. And he reminded us that on 4th July, the Financial Times proposed that the PCTs be turned into one giant health insurer. Roger highlighted eight ‘tests’ for insurers – and PCTs meet three of the tests, don’t meet another three and possibly meet the remaining two.

Roger identified his top-10 risks facing the NHS. And in reverse order they were:

10. The NHS will run out of money in the longterm, and not before the next general election (possibly June 2010). 2008 is the year when demand is running ahead of budgets and at the same time, PCTs are spending just 15% of what the private sector spends on managing Commissioning – the suggestion here is that PCT Commissioning functions need to be better funded and by implication, they need a greater range of skills in their teams.

9. Practice-based commissioning will not gain traction. While it is estimated that only a third of GPs will be willing and able to make practice-based commissioning deliver in the way that PBC advocates suggest, by increasing PBC activity, the NHS has the potential to redistribute significant amounts of money – with GPs switching patients from one Acute Trust to another.

8. Block contracts remain impenetrable to PCT scrutiny and validation, including mental health block contracts - see Risk 10 above about PCT Commissioning functions.

7. PCTs need to invest more in management systems. In other words if PCTS don’t put aside money to invest in management systems, they’re unlikely to get control of their PCT finances – links with Risk 10 !

6. The supply side will shrink - reducing competition and choice. This will be a consequence of Trust mergers and some of the private sector providers (including ISTCs) retreating from NHS provison

5. Patients need more encouragement to play their role in re-shaping the market. Consumer surveys consistently show that consumers want choice. Patient Choice has much more to do, if it is to achieve its potential.

4,3 and 2 - Is Monitor encouraging Foundation Trusts to be too aggressive in developing their financial strategies (?) through:
- the pursuit of earnings before interest, tax, depreciation and amortisation as a key measure of success.
- the building of significant capital reserves on FT balance sheets
- service line analysis which could lead to huge distortions in provision

PCTs that transfer money to their local FT and other providers are transferring the financial risk to themselves! They are also in danger of losing control of Commissioning. Armed with the management tools developed by Monitor, FTs may choose to cherry-pick the more financially profitable specialties and procedures. And FTs could choose to unilaterally decommission services, putting patients at risk.

1. WCC will not move fast enough - or fail.

What a thought-provoking presentation to end the day. And it suggests that provided PCTs implement robust risk management processes and they invest in management systems, then World Class Commissioning is likely to become a reality.

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09/10/2008 by Patrick Keady.

‘The most difficult time for us is when we come up with ideas that no one else has done. This is a key moment. To start to do something about it’

Sir Ranulph Fiennes Bt OBE, The English Mutual Lecture, 9th October 2008

I was one of the lucky 730 people that attended Sir Ranulph Fiennes’s lecture at Worcester Cathedral, in aid of The Wealth of Happiness Foundation. Described by the Guinness Book of Records in1984 as the “World’s Greatest Living Explorer”, Sir Fiennes gave us an insight into what motivation means to him.

Since his birth in 1944, Ranulph served with the Royal Scots Greys, the SAS and the Sultan of Oman before taking up a career as an expedition leader.

He was at the forefront of many exploratory expeditions - the British Expedition on the White Nile 1969; Transglobe (the world’s first surface journey around the world’s polar axis) 1979-82; North Polar Unsupported Expedition (furthest north unsupported record) 1986; Anglo-Soviet North Pole Expedition 1990/91; co-leader of the Ubar Expedition (which in 1991 discovered Ptolomy’s long-lost Atlantis of the Sands, the frankincense centre of the world); leader of the Pentland South Pole expedition 1992/93 (which achieved the first unsupported crossing of the Antarctic Continent and the longest unsupported polar journey in history).

People’s motivation was the principal reason why Sir Fiennes accepted people on to his teams. And his motivation? He told us that in Antarctica, he could sack someone from his team but that it’s very difficult to get rid of them! Ranulph defined motivation as the sum total of everything that happens to us since childhood and how we react to it. And his motivation? Trying to stay ahead of the rivals. He added that you’ve got to be first; it’s no good being second.

Despite suffering from a heart attack and undergoing a double heart bypass operation just four months before, Fiennes completed seven marathons in seven days on seven continents in the Land Rover 7×7x7 Challenge for the British Heart Foundation (2003) – Patagonia (South America), Falkland Islands (Antarctica), Sydney (Australia), Singapore (Asia), London (Europe), Cairo (Africa) and New York (North America)

Speaking after the event, Fiennes said his cardiac surgeon had approved the marathons, providing his heart-rate did not exceed a 130 beats per minute; Fiennes later confessed to having forgotten to pack his heart-rate monitor, and as such does not know how fast his heart was beating.

Sir Fiennes showed many photos but my favourite was a chameleon. He told us that the colour of the chameleon could blend into the background. In green vegetation, it can change to green and in red vegetation it can change to red. But if the background was multicoloured (e.g. a tartan rug), then even the Chameleon would have a problem blending into the background!

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29/06/2008 by Patrick Keady.

The NHS is 60 on Tuesday. Happy birthday to a British treasure that is respected at home and around the world.

And tomorrow, Lord Darzi publishes his views on how the NHS can enhance that respect by delivering even better healthcare over the next 10 years. Further changes in NHS strategy are quaranteed. And as we know, implementing strategies can be challenging. Which reminds me of a research paper that I read recently. Based on the views of 35,000 people, the paper highlights just four areas that make (or break) the effective implementation of strategies.

My view is that by focusing on these four areas, professional groups, SHAs, PCTs and Trusts will be well placed to respond to Lord Darzi’s challenges. The four areas are information, decisions, motivators and structure. Here’s my initial thoughts on how NHS organisations and people working with NHS patients, can be better placed to deliver even better healthcare over the next 10 years.

Information - that important ‘competitive’ information gets to Boards, PCTs, SHAs and the Department of Health, more quickly – from patients, staff, independent healthcare providers, charities. That information flows freely across professional and organisational boundaries. NHS employees and other people employed to work with NHS patients, understand the real impact of their day-to-day choices on patients. Middle managers and clinicians have access to the information that they need to measure the key drivers of their service. That sources of conflict are acknowledged and responded to appropriately.

Decisions - reducing uncertainty will ensure that all people working with NHS Patients, understand the decisions and actions that they are responsible for. People will be clear about the impact of their decisions. They will be happy to be held accountable. Senior clinicians and managers will continue get involved in decisions at speciality/Departmental levels. The culture moves further towards ‘persuade and cajole’ and away from ‘command and control’. Human Resources, Finance and other corporate roles further change their behaviour to support Specialities and Departments.

Motivation is the third driver. Performance will focus more on outcomes – differentiating between high, adequate and low performers. Career advancement and salaries will be strongly influenced by the individual’s ability to deliver on their performance commitments. Even when an NHS organisation has a bad year, and one of its Specialities or Departments has a good year, the Speciality/Departmental gets a bonus – the team earns greater autonomy and financial support to further develop their Speciality/Department.

Structure. Increasingly, promotions will be from one position to another on the same level in the hierarchy. Fast-track employees can expect to be promoted upwards, at least every three years. Middle managers have a minimum of five direct reports.

So there you have it - my thoughts on four drivers that will help translate Dr Darzi’s thoughts into reality. Having worked with the NHS for 17 years, I know that we have the ability to achieve this. My gut-feel is that we will exceed! Here’s to even better NHS outcomes over the next 10 years.

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23/05/2008 by Patrick Keady.

Josephine Ocloo

Krista Ocloo, was born in 1979. Her congenital cardiac abnormality was successfully repaired at an NHS Hospital, shortly before Krista’s second birthday. She went on to enjoy a happy and normal childhood and early teen years. But in 1995, Krista started to complain of chest pain. In January 1996, she was admitted to the same NHS Trust for an exploratory catheterisation.

Krista’s mum, Josephine, was assured by the NHS, that Krista was perfectly all right and that an appointment would be booked for another check-up. Krista was discharged but the appointment was not scheduled until January 1997.

On 5th December 1996, Josephine found Krista at home in bed …….. Krista was dead. The post-mortem revealed death from acute heart failure.

Josephine Ocloo, relayed her story to the 600 delegates at today’s Patient Safety Congress. The Nursing Director next to me, stopped taking notes. She placed her notebook on the floor and gave her undivided attention to Josephine Ocloo. Josephine then described how she tried to get answers from the NHS Trust. Josephine wanted to know why Krista had died. SheJosephine described an NHS that was at best, unhelpful. Around me, I saw some tears, I heard lots of sniffles …… and there was very little note-taking.

Krista died before the introduction of Clinical Governance, the Turnbull Report, Choice and Competition as we know it today. But what can today’s NHS do to ensure that all of today’s patients get a better service than Krista received 12 years ago? Professor Bernard Crump (Chief Executive of the NHS Institute for Innovation and Improvement) asked delegates for their thoughts. He asked them to identify which one of the following can best improve patient safety

1. Regulation and Standards
2. Commissioning, Competition and Choice
3. the personal motivation of NHS professionals, leadership

David Nicholson, Chief Executive of NHS England, told us that delegates and the NHS in general, needs to be clear about the services that we want to deliver for patients. He added that techniques such as PDSA, Lean etc, together with new behaviours, will help.

Don Berwick, President and CEO of the Institution for Healthcare Improvement, added that improving healthcare needs to be embraced in every hospital, by every GP practice and by all healthcare professionals. Professor Cecil Helman alerted us that the definition of health, continues to change. Since the NHS was established in 1948, the definition of health has fragmented into physical, psychological, social and spiritual. David Dalton Chief Executive at the Salford Royal NHS Foundation Trust, joked that his organisation was ‘crap at implementation’. He then added that his Trust reduced Clostridium Difficile infection rates by 70% in 10 months. The Trust achieved this by empowering staff to identify the problems that they wanted to deal with, and giving them the necessary support. Sir Liam Donaldson, Chief Medical Officer, suggested that in 2018, infection prevention might be achieved with the help of sensors, that there might be voice operated electronic prescribing, checklists in surgery and an aviation-style ‘black-box’ in operating theatres. Peter Walsh, Chief Executive of Action against Medical Accidents, pointed out that NPSA Being Open, is only guidance. He urged for a major uptake of training in NPSA Being Open. Rashmi Shukla highlighted the characteristics of a safe system. Eamonn Kelly identified how World-Class Commissioning, the Assurance Framework and the Standard Contract for Acute Services can improve services. Katherine Fenton challenged the role of Strategic Health Authorities, adding that it needs to shift towards motivating their PCTs and Trust improve. Sarah Andrews added that while NHS targets can be useful, the NHS will benefit from celebrating it’s achievements. Gerry Marr from NHS Tayside highlighted how data owned by Clinicians is being used to show decreases in Hospital Acquired Infections. Data from Clinicians in Tayside, will be used to confirm a 15% reduction in mortality and a 30% reduction in adverse events. Martin Fletcher, Chief Executive of the National Patient Safety Agency highlighted Royal Gwent where there is a 95% compliance with hand hygiene, more than twice the average compliance of 40% in England and Wales. This high level of compliance was achieved because of strong leadership, the use of an effective implementation tool, the measurement of outcomes and providing feedback to staff. To be a Regulator or not to be a Regulator, that was the question! Paul Philip (General Medical Council), Sarah Thewlis (Nursing and Midwifery Council), Gary Needle (Healthcare Commission) and Simon Gregor (Medicines and Healthcare products Regulatory Agency) were all proud of their roles as Regulators. But Professor Bruce Campbell (National Institute for Health and Clinical Excellence) and Professor Dame Joan Higgins (NHS Litigation Authority) emphasised that their Organisations were not Regulators.

And what responses did delegates give to Professor Bernard Crump’s poll? 3% of Delegates voted regulation and standards as the most effective approach to improving Patient Safety. 2% went for Commissioning, competition and choice. The other 95% opted for the personal motivation of NHS professionals and effective leadership.

Is it a coincidence that in the 12 years since Krista’s death, we have seen a plethora of activity in the areas that received the fewest votes? – regulation, standards, commissioning, competition and choice.

It is refreshing that based on the messages from these speakers, that effective leadership and the motivation of staff is leading to dramatic improvements in parts of the NHS.

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18/05/2008 by Patrick Keady.

After watching the BBC2 programme Wild China, I was left wondering if there are similarities between NHS teams and the fishing team featured in the programme.

The BBC2 programme introduced men in their 70’s and 80’s. They chant and dance on rafts and are assisted by their well-trained team mates ….. a group of Cormorants. Between them, the team catches up to 30 decent-sized fish in a morning.

On Friday morning, the NHS England Chief Executive published The Year 2007/08. In his annual report, David Nicholson confirms that NHS England is on track to reduce waiting times to one sixth of what they were 10 years ago. By the end of 2008 all patients will wait less than 18 weeks from the date that they are referred by their GP, to date that they are treated.

In the opening paragraphs, the Chief Executive mentions that NHS England went through one of its most significant restructures in 2007/08. With the introduction of Modernising Medical Careers, 30,000 NHS Junior Doctors were left to compete for around 23,000 posts. About half of the pre-merger Strategic Health Authority employees have gone. Up to half of the pre-merger PCT employees are no longer there. And in the 2006/07 financial year, 1000’s of NHS Trust employees became surplus to requirements. Do we know where these people today?

NHS England successes during 2007/08 include rates of MRSA bloodstream infections in acute hospitals being reduced by 50%. All NHS patients in England are now free to choose where their elective care takes place. The median waiting time for diagnostic tests is 2.1 weeks, compared with 6.1 weeks in April 2006. All patients wait less than 4 hours in Accident and Emergency Departments.

While these are fantastic improvements, Mr Nicholson adds that more needs to be done. Lord Darzi’s plans for the next 10 years, are being published. They provide an excellent opportunity to bring about real and lasting improvements for all patients in England. The Chief Executive acknowledges that his job - and that of every leader and member of staff in the NHS - is to seize this opportunity and to make it happen.

The fishermen in Western China seize their opportunities too. But the Cormorants on the Lee River are aware. They keep a tally of the number of fish they catch, up to 7. And after that, they expect to be rewarded, or they withdraw. We know that NHS staff are keeping a tally too and that it has far exceeded 7! The reward that NHS staff often want is simply to be thanked for yet another job well done. NHS staff value job security, job satisfaction, good working conditions and appropriate training.

Many NHS organisations are responding well to the expectations of their staff. The NHS is clearly improving its services to patients. But after one of the NHS’s most significant restructures, an important challenge for all NHS organisations is to continue motivating and acknowledging the successes of their employees.

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