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

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

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.

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:
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.

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