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February 9, 2011

Welsh Institue of Health and Social Care Blog
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» History teaches us that working together works

It’s useful, now and again, to look back on our past successes. 

This is not just to make ourselves feel good – although a little bit of that now and again does no harm – but to learn the lessons of the past.

To twist a phrase, those who don’t learn the lessons of history are doomed not to repeat them.

Almost at random, let’s look at three different successes which NHS Wales (and its partners) can justly claim from recent years, and see what they might teach us about the future.

First, learning disability services:

Almost a generation ago, the NHS and social services in Wales changed the face of services for this client group. Working together, they moved people out of Victorian institutional warehouses into housing in normal streets up and down the country and put services in place to support them there.

At the heart of this success was the sort of genuine joint working that we need now across most of health and social care.

The agencies overcame their many differences and worked together on a common goal because the Welsh Office (as it then was) made joint working all but compulsory and provided clear cash incentives to do so.

Secondly, the abolition of waiting times:

This massive achievement in our current decade is of historic proportions.

Within a few years, people’s biggest and oldest bugbear about the NHS – inordinate waits for treatment – was ended. Why? Because for once we bent every sinew to the task, we matched this with resource and we stuck at it until the task was achieved.

Thirdly, the 1,000 Lives campaign:

This is still very much in progress – in the guise of the five-year, 1,000 Lives Plus programme – but it has already achieved impressive improvements in the quality and safety of care in pretty much every hospital across Wales.

The lesson here is that if you can find a cause which unites both the professionals and the managers, you’ve got a good chance of getting somewhere.

The win-win – better care and greater efficiency – must also be good news for patients and taxpayers too.

You could also add to this happy trio the huge improvements in dental health we’ve seen over the last couple of generations – most children now have no fillings, compared with the serried rows of grey metal in their parents’ mouths – and the huge growth in GP and community services.

These two examples show what can be achieved when we get patients and services to work together, for example applying fluoride each day and regular visits to the dentist, and by lining up the resources and incentives in GP services.

So what does this teach us for the future?

Five lessons of great relevance – make joint working unavoidable; get patients and professionals to work together; find common ground for clinicians and managers; line up incentives and resources; and choose a small number of priorities and stick with them.

History tells us this is all possible.

A quick glance through the rest of this newspaper tells us that it’s now more necessary than ever before.

Written by Professor Marcus Longley, Director and Professor of Applied Health Policy

This blog is reproduced from Marcus Longley’s column in the Western  Mail on 7 February 2011


March 24, 2010

Welsh Institue of Health and Social Care Blog
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» Out of dependency…

The dominant model (I don’t say the only model) of doctor-patient consultation privileges one viewpoint: the doctor’s. The relationship is a power relationship in which the doctor remains largely unquestioned and the patient is mostly powerless.

Whether benign or not, the balance of this relationship may be shifting, indeed has to change, if we are to deliver world-class health outcomes for users of health services in Wales, and to do so within the financial constraints the NHS is facing.

Last Tuesday’s Times (16 March 2010) published a letter (We must treat our minor ills ourselves) signed by a number of doctors and related professionals bewailing the fact that the ‘worried well’, half of them of working age, now represent approaching 20% of GP time. The ‘catastrophic impact of this dependency’ is detailed in the accompanying full-page (3) article (Workforce wimps cost NHS billions)which ‘demonstrates’ the huge costs of attending to the minor ills of half of those making 51.4 million visits for colds, headaches, back pain, indigestion etc: £2billion annually. (This is not to ignore the fact that, in a few cases, the presenting minor problem masks a deeper more serious disease or condition.) 90% of those visits for minor ailments resulted in a prescription.

In one way, the perception that patients, by and large, are powerless, might be challenged when we see them as having the capacity to drive the NHS this way. But GPs speaking about their own ‘victimhood’ behaviours, in an unreasonably demand-led culture of service use, does not change the central fact of the relationship that people have with their health professionals. If they have learned to be sick, to roll over and adopt the position of acquiescent or plaintive patient, so too have doctors learned to treat them in ways that remove most of their best opportunities for self-management. Launched in their letter to the Times, the Campaign for Self-Care has to be careful not to make the same mistakes.

If GPs feel compelled to (merely) manage ‘insatiable’ patient behaviours, then surely mitigating those very problems which affect the users of their services will bring them immediate benefits as practitioners? The way that people can be ‘empowered’ to better manage their health conditions, and not just minor ones, can lead directly to relieving the worst aspects of the ‘patient experience’, creating better health outcomes and contributing to the shift in behaviours that could, the Times suggests, lead to £10bn saving over five years. Unfortunately the emphasis in the article is mostly on (negative) patient behaviours: when the question of how doctors behave arises Dr Dixon, a GP from Devon, is quoted as saying: ‘…health awareness [on behalf of the patient]…needs to be balanced with more information on when you need to see someone [or not]. We have become merchants in investigations and referrals and our teaching role is one we need to invest in as well.’

The role of doctors as teachers of self-management skills is welcome. Self-managing health conditions is a very real solution to demand-led dependency. But users of services cannot become wise and responsible users without the tools to do so, and responsibility for their behaviour change cannot be simply expected of them without those tools. The opportunities to acquire them have to be grown rapidly and widely.

Empowering service users is not a question of defeating them in a war of attrition; enabling them to learn the skills to re-orientate their expectations, and to be well-informed about the decisions they do (need to) make, depends on giving them the power to engage in decision-making and act positively based on knowledge. The architect of the NHS, Aneurin Bevan once said ‘The purpose of getting power is to be able to give it away’. Practitioners need to recognise that their part in the dependency culture is not just better management of patient behaviours and expectations, but their own too. Genuine partnership is the key tool to achieve the win-win-win for patient, practitioner and organisation together.

Better outcomes, better use of scarce resources (practitioner time, money etc), depend critically on building a better focus for delivery of healthcare, and enabling all parties to behave differently when appropriate. If 90% of people who turn up in front of their GP with chest pain have no event or disease, then why on earth are we not enabling those people to make better decisions about their situations to everybody’s benefit? This does not preclude calling 999; far from it. But it means doing so when there is good reason, and knowing what a good reason looks like (thus, by contrast, knowing what is insufficient to warrant intervention). It means not heading to the GP with a sniffle, but knowing what to do if that cough begins to create breathing difficulties.

We have been conditioned to ‘play patient’; the NHS makes us ‘sick’. But being sick is not the same as having a disease or health condition. Disease is objective, medically diagnosed pathology; illness, the feelings that are associated with some disease/condition. Sickness however, is a social status granted to the person who is ill. It is a means to getting time off work, benefit support, a cup of tea in bed with some paracetemol, sympathy, help. We still incline people to play the sick role, and reinforce it by constantly refusing and indeed removing opportunities for patients to become informed, decision-making, service users, real partners in their healthcare and condition management.

The doctor’s armoury has relied in the past on their prestige as experts: we generally think of those who get the chance to study medicine as being amongst the brightest. This intelligence puts them in a class of decision-makers that others can feel uncomfortable to challenge. Added to this, their professional expertise, especially because of the inherent nature of healthcare giving, quickly creates a locus for unchallenged opinion based on that expertise. When a doctor says take this pill and you will feel better, have this operation and we can save your life, how can we be surprised that people jump immediately and uncritically to rely on that expertise?

Carry on Doctor, nowdays deeply culturally insensitive, caricatured this model of delivery, but Sir Lancelot Spratt would not have been remotely funny at that time if the parody did not strike at a truth. Some older (no disrespect) consultants will admit they were trained to act like ‘gods’. Sadly, a few, and not just older practitioners, still think they can act this way with impunity and resent any challenge to their power as doctors.

But challenge is not always for its own sake: joint-decision making is nothing to fear or resent.

There have been attempts to enable patients to become managers of their own conditions and sometimes these work well enough. They just don’t travel far enough, and perversely, some patients are reinforced in their roles as ‘sick’. Additionally, programmes to teach patients to become ‘experts’ are flawed. There is a false opposition between the patient’s ‘expertise’, living their condition, and medical training and experience.

Real partnership in healthcare does not dispense with medical expertise. On the contrary, such partnership continues to rely heavily on the professional’s gifts and training: it is the nature of that reliance, away from dependency to condition management, away from the medical model to medically supported decision-making, which is the step-change required now.

‘Incorporating the patient’s viewpoint’, i.e. bringing this into the doctor’s model, not giving it genuinely equal status, nor rearranging the entire relationship between ‘perspectives’, is not a solution. The Calgary-Cambridge guide to medical interviewing (all 71 points of it) still fails to address the key solution, as current condition-management programmes still fail to achieve the desired better health outcomes, better use of GP and other health practitioner time and better organisational returns in terms of the available cost-benefits. ‘Patient-centredness’ is not enough.

I was involved in a trial to support patients admitted with stroke/CVAs through the A&E; of one of the largest acute hospitals in Northern Ireland. A multi-disciplinary team (MDT), physios, OTs, nursing staff, social workers, speech therapists and any other relevant professional, all led by the consultant in charge, set out to improve services to emergency admissions and to create better outcomes for people with strokes. The person missing was the patient (and/or patient representative), but that was in 1978!

To this day, MDTs meet regularly in hospitals and still the person missing is the patient. We want people to stop adopting the sick role, to deal with their illness and disease or condition in a way that can defeat the pressure of insatiable demand for services. But we will not countenance the very thing that will bring this about.

The move to patient-centredness is certainly not new and may be already tired, especially when we have so demonstrably discouraged patients from building any skills that would allow them to self-manage appropriately. Imposing solutions from an organisational point of view won’t do either in a modern age: practitioner and organisational need cannot be served before service user outcomes if the world-class health outcomes are to become real. We cannot be satisfied with patient-centredness, especially in the absence of the person whose life it is.

The NHS has moved from its first days where doctors and opticians were directly engaged through the monies contributed by Tredegar miners and steelworkers, to serve the health needs of the community. In the 21st century we need (again?) a relationship in which the patient is the primary decision-maker, but their informed decision-making is in equal partnership with the expertise around them. We can reduce the dependency relationships patients have with the NHS, but we need do it in an intelligent and sustainable manner.

Written by Dr Kevin Fitzpatrick, WIHSC Associate

1. Waddell, G & Aylward M The scientific and conceptual basis of incapacity benefits TSO 2005 (p7)

February 22, 2010

Welsh Institue of Health and Social Care Blog
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» NHS Wales' Waiting Times: The Sustainability Challenge

In commenting on the latest figures, Edwina Hart, the Assembly’s Health and Social Services said: “this is a significant achievement, and one of which staff should be proud” and that “the priority now for the NHS must be to sustain these targets”.

While many will share these sentiments, we need to be cautious not to underestimate the challenge of maintaining our progress. A lot of money has been thrown at waiting times to fund a sterling effort to get where we are. From a political and public point of view, it was right to bring waiting times under control – the reputation of health policy and the effectiveness of the NHS was at stake.

But many working in the NHS have had concerns about this initiative distorting clinical priorities, applying short-term fixes, and paying over the odds. This is not to deny that innovation, improved efficiency, and best practice have also played a big part in the success. But there is a danger that the waiting time programme could be seen as one off event rather than a coherent strategy with underlying policies, systems and processes aimed at maintaining, acceptable and sustainable waiting times.

As with all publically funded services, the NHS is facing a decade of intense pressure on its funding. One way or another the health pound will be increasingly stretched. This not only challenges the maintenance of existing waiting times, but it underlines the fact that the range and infrastructure of today’s health services is unsustainable.

The local plans emanating from the Welsh Assembly Government’s 2006 strategy, Designed for Life, were not well received by the public, the authors would likely present them differently today. But their direction and themes remain essential if we are to provide sustainable health and social care services through the 21st century. To be fair, all this is writ large in the documents that led to the restructuring of the NHS in Wales, and the new Local Health Boards are clear about what they have to do. They must deliver a patient centred care approach, with patients able to exercise as much or as little influence over their care as they choose, except where strong evidence advises against it. They must also provide services that are efficient, effective, timely and safe in a health service that changes the balance of care into people’s homes and communities, and away from traditional hospital care. The implementation of Dr Chris Jones’ primary and community services strategic delivery programme will be the precursor of a major review of what hospitals do and where they are strategically placed. What is clear is, things cannot go on as they are.

Fortuitously, a byproduct of all this talk about the cutbacks in public money, citizens may be softened up for change, but with health and social care, we can’t take that for granted.

To put the service changes now envisaged in context, if you keep people out of hospital, then they won’t have to wait to go in!

Written by Mike Ponton, Senior Fellow, WIHSC

December 10, 2009

Welsh Institue of Health and Social Care Blog
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» A plea for patient-centredness

I was recently engaged in a study to assess the information and service needs of people with serious mental health problems, when a young woman told me:

"When I am ill, I want to be sure that I receive the best treatment available; 
  when I am better, I just want to get on with my life."

At the time, this statement provided justification for Hafal’s approach to collecting ‘evidence’, which is to record statements in a book, as their members make them. When the appropriate consultation paper is published, the comments are available for use. It avoids the need for Hafal to consult its members when they are either too ill to comment or well enough not to be interested. We can all learn from this approach when seeking appropriate, accessible and timely methods of consultation.

However, this comment has also a deeper personal meaning for me, whose quite well-developed cancer was discovered by chance and not through screening. How many of us, when we are ill, can really be sure that we receive the best treatment available? And what do we mean by the ‘best’? Is it the treatment that produces the best long term outcomes, or the treatment that has the least limiting side effects and allows us to get on with our lives most easily? I went through the cancer treatment with the distinct impression that there were two battles going on – my Oncologist was fighting my cancer, while I was fighting to retain the comfortable, pain-free life I once knew – this was never a subject we talked about. The NHS ‘system’ is like a sausage machine, seeking to respond to the needs of the whole population, but insufficiently seamless or adaptable to the needs of any one individual – and the ‘fit’ to one’s personal needs is often very poor.

The other lesson from all this, one which I plan to do something about, is that if you want to be sure of receiving the best treatment available and achieving the best quality of life afterwards you need first class information, advice and support. I was extremely fortunate in being ‘information literate’, in being able to ask the right people relevant questions, in having sympathetic and supportive practitioners with whom I could communicate, in having knowledgeable friends and associates, and being able to afford commercially provided treatment and equipment. However, for those people, who do not have the energy, motivation, or means, this is simply not available – and often people are left in a state of depression and morbidity, regular visitors to their GP and an ongoing burden on the NHS. It could be so different.

I was so pleased to hear of the initiative of Macmillan Cancer Support, which is working with Rhondda Cynon Taff libraries to provide appropriate information in libraries and train its library staff in dealing sympathetically with enquirers. Macmillan is hoping to spread similar initiatives to other parts of Wales, part of a strategy which I hope will lead to better understanding of and responsiveness to the information needs of patients and those of us living with the legacy of treatment and wanting to get on with our lives.

I would like to know of any other initiatives in this area – please post on the blog.

Written by Katherine Hughes, WIHSC Associate