Cats, power and building barriers in the NHS

In the last year or so we have talked a lot about NHS culture in the media, blog posts and in the Francis inquiry. How the culture is wrong, how we need to change culture. I think we use “it’s the culture” as an excuse to keep doing what we have always done and so we get the same results. Saying it’s the culture is also a way to quieten down those who might challenge the status quo.It all then becomes about keeping going and survival. Some NHS managers and leaders act like my cat when another cat enters her territory.

In the garden today I can see my cat on the fence in a “Mexican standoff “with a black cat. Hissing and howling and just sitting, balanced on a fence refusing to shift. My tabby just digs in and exerts her power on the status quo. I’m not shifting, this is my yard and you are not getting in. Eventually of course the stranger leaves and my cat goes back to lying in the sun and cleaning her belly! That’s pure power and the status quo is protected.

Of course patients and their families are not an enemy cat and the status quo of health care is meanwhile falling around our ears. We are more than just animals guarding our territory and we need to use different and more sophisticated strategies to move the NHS forward. We need to genuinely engage in co-production, listening, changing and developing new solutions with patients and their families. Some are already leading this change across the NHS.

I am currently working with TLAP, The NHS Confederation and NHS England on bringing personal health budgets to mental health. I have worked on the personalisation agenda now for many years starting with direct payments in social care when I was an Assistant Director, then as a DH official leading a regional team and most recently as an Executive leading strategy on a Foundation Trust Board. So, I know a little about this agenda.

On the 9th July 2014, NHS England Chief Executive Simon Stevens, announced his intention to drive forward a new form of radical, people-powered commissioning of health and social care, including the extended use of personal health budgets and integrated personal budgets across health and social care. The Integrated Personal Commissioning (IPC) programme, starting from April 2015, will bring together health and social care funding around individuals, enabling them to direct how it is used for the first time (NHSE press release 9th July 2014).

It’s a no brainer on one level, we are great at lifesaving emergency care in the NHS BUT when we organise care for people we don’t often get to the nub of what would make a difference to their life, independence and health condition. We give drugs and support these interventions with health professional visits. Many, many years ago when I was a baby community team manager I worked with a couple of inspirational psychiatrists (one of whom is a National Medical Director at NHS England now.) They taught me so much about what makes good health and good mental health. One of them said they always visit patients with complex mental health problems at home. As the drugs and support from community teams will do nothing if they sleep in a flat with no door, no furniture, no heating and have no friends and no food. Now that’s simply what Marmot talked about in

http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review

So, at its core that’s what personal budgets offer. The chance to help individuals answer the questions : what helps me stay well, out of crisis and what could we do to put those things in place for you? So together we can help people with complex needs and their carers have better quality of life, more people are kept out of hospital and care homes and people can access personalised, coordinated services for their whole life needs.

The evidence suggests people want to be more actively engaged as partners, that services frequently underestimate their willingness and that the potential impact of harnessing this contribution could have huge economic value and lead to better outcomes. Approaches that personalise support to people’s level of activation, that build skills and confidence and use peer-support have been shown to have a positive impact. Additionally, people who start at the lowest “activation levels” have been shown to improve the most, indicating the opportunity for a personalised approach to support the least engaged and challenge health inequalities.

So what is stopping us? I think we behave like cats, thinking we need to be tougher, more managerially focused with more fire power or action plans and project teams to solve the problems of no money and increased demand. Because we ultimately do not trust people to manage their own care and we do not trust our clinicians to make this move to facilitate rather than direct care and support. It is called the professional gift model
http://www.centreforwelfarereform.org/library/by-az/citizenship-professional-gift-models.html

Deep down though we know that fear only leads to more stand offs and more of the same. We know more of the same of the NHS is not sustainable. So we need to move at scale and speed to coproduce care with the patient. Start trusting patients and families to decide and using professional expertise to facilitate the support provided. Already lots of great examples abound of how to do this and stories of where it’s already happening.
http://www.thinklocalactpersonal.org.uk

Or you can just sit on that fence howling at the strange cat and hope your territory stays the same. I tell you it will not as change is coming and fast. So, for my colleagues and patients and family carers leading this exciting work:

Labbi siffre said: Brothers and sisters
When they insist we’re just not good enough
Well we know better
Just look ‘em in the eyes and say
We’re gonna do it anyway
We’re gonna do it anyway

National Voices recently published Evidence for Person-centred care drawing together evidence from systematic reviews of different approaches incorporating support for self-management and shared decision making, promoting prevention, improving information and enhancing the experience of healthcare: http://www.nationalvoices.org.uk/evidence
What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs Hibbard JH, Greene J. Health Aff (Millwood). 2013 Feb; 32(2): 2017-14.
Hibbard JH, Greene J. “What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs.” Health Aff (Millwood). 2013 Feb; 32(2): 2017-14.

I dream of things that never were, and ask why not?

It’s almost a year since I set up my company Blend Associates Ltd. So whilst I’m not one for Christmas newsletters it seems right to do a little stock take.  Those of you who have followed me on twitter and read my blogs will know it has been a bit of a roller coaster. Life’s thrown curve balls my way and I’ve tried to be strong and bold and hold my nerve.

I’m known by many for my dispassionate logic and reason, but I’m also marked by my passion and courage (some say bloody mindedness!)  I have needed to engage with these qualities to identify who I am, what would I do, and how on earth do I make a living going forward.

When I was leaving the NHS some key confidants helped me think beyond the loss of career and making a difference on the inside of the public sector to the opportunities that lay beyond. Well, didn’t get that one straight away! I was in the maelstrom of self-pity, despair and worry and I felt at times vulnerable.

What I now had in buckets was time. So, I started to think on what I had covered in my career. Not the stuff you have to do to deliver your job and meet your targets but the stuff that energised. The stuff where I felt I made a difference to patients, their families and the wider public service offer to the tax payers. A few key words kept coming through –Big plans, passion for people, make a difference, intolerant of less, equality, connection, energy.

One day my hubby said BLEND. In cooking you take individual ingredients, BLEND to make something better. So it is with wine and paint colours and pigments. I sat with it a few days and thought yes it sums me up. BLEND it was, and I turned my attention to what the company would offer and three words came to mind:

STRATEGY looking ahead and moving forward, the big plan in conditions of uncertainty or inertia. Looking left, looking right, challenge the status quote. I bring clarity about why we are here, where we are going and who we are here for.

INTEGRATE combining things to complete them, sitting at the edge of organisations, bringing disparate groups together, ensuring all have a voice, not just the big guys. If we integrate anything it takes huge effort so it’s got to make what we offer better and make sense to the patients and their families.

COACHING this one is about reaching out, being with the leader, helping them find their way like many others have coached and counselled me. I realised I love people, I’m fascinated by them, and what makes them tick. Giving them the space to think, and if they want to learn they will find a better way.

One day I Google, looking for quotes and there I found him and this:

” The future does not belong to those who are content with today, apathetic towards common problems and their fellow man alike, timid and fearful in the face of bold projects and new ideas. Rather, it will belong to those who can BLEND passion, reason and courage in a personal commitment to their ideals.” Robert F Kennedy 64th US Attorney General.

If you were born in the 60s like me, you are unlikely to know of him, he was the younger brother of JFK and his right hand man in the West Wing. The strategist, the reformer, passionate about civil rights and friend of Martin Luther King. Straight talking, spoke his mind, offended some with his record for cleaning up organised crime…..Then elected New York Senator oh and they shot him on his own Presidential run.

This sort of courage passion and reason are vital if we want to see real, sustainable, people based change to our public services. So, here I am a year on now I run my own company offering strategy, coaching and business consultancy to both the public and private sector. I have had a number of great commissions and across the range of my interests too. This past 6 months I have worked to support CEOs, Boards and national organisations. In areas including board diversity, mental health, learning disability and personalization. I have also just been appointed as a non-executive director of my local community trust. So this girls back on a board. And I submitted my ILM level 7 Executive Coaching Dissertation to OPM in November. So I might just get a certificate in the New Year!

What have I learnt? Doors swing both ways. Some do close and others really do open. Some of the new rooms are also better than those you left! Be strong – even if today feels tough it will be better tomorrow. Be bold – step out, reach up and aim high. Be big – present yourself to the world based on what you can offer not what you are doing today. Be creative – try new things and talk to lots of different people. Most of all Be authentic and  take enough time to Be still and have faith – in what you believe in, in yourself and your ability and in those who say you will be ok. This Christmas cheers to all of you my customers, fellow consultants and all who have helped me this last year. Let’s look forward together to 2015.  One thing I didn’t anticipate in 2014 I now work with a guy who makes the best cricket bats so #putoutyourbats.