In a recent online blog, respected NHS manager Roy Lilley suggested there are some simple questions to ask ourselves.

“Will we have more older people to look after? Yes. More. Are the structures we have in place robust enough to cope with more? No. Would it make sense to have one agency handling this gigantic challenge? Yes.

It’s time for a rethink. If we are really talking designing services around the needs of the user then it’s time for a Silver Service; dedicated and developed around the needs of the frail elderly. Bespoke services supplied, end-2-end, by a single agency.

So why don’t we do it?”

I sent his message around the GPs of Leicestershire to see what they thought. One response said it all:

“Almost everyone knows what the problem is ! It’s about how do we do it? The most famous word Integration remains on paper!”

But why?

As one wise GP told me ‘Follow the money’.

We cannot achieve partnership across organisations until their leaders, cultures and, crucially, financial best interests are aligned. Here in Leicestershire, A&E is in crisis and our acute provider University Hospitals of Leicester NHS Trust is in deficit. Failed discharges and re-admissions cost University Hospitals of Leicester money. The Council (LCC) are slashing Adult Social Care budgets making it harder to keep the frail elderly safely at home.

‘Better Care’ will pool funds from both LCC and University Hospitals of Leicester so that care can be provided in the community – by our community provider Leicestershire Partnership NHS Trust and GPs. There is nothing to pump-prime the transformation so we are robbing Peter to pay Paul. We also have three Clinical Commissioning Groups – all with slightly different approaches to the problem.

It doesn’t help that NHS England is protecting its own budget by cutting GP funding and holding back on the development of GP premises. The latter is frustrating District Council planners who are having hand back developer contributions. Why? Because better premises will put up the rent paid by NHS England to GP contractors.

In a cash-strapped health economy, without coherent system-wide leadership, Leicestershire risks developing a bunch of providers (GPs included) who are more interested in saving their own skins than co-operating.

One desperate voice asked “Maybe we need a crisis to break down the silo mentality?”

To which others replied “We’ve already got one!”

Do we ‘need’ a crisis?

I’ve just had half an hour on the phone (as County Councillor) with a distressed daughter whose frail mother has just had appallingly dis-coordinated care. Patients are suffering crises like this every day. What we need is system-wide leadership that allows front-line clinicians to address poor quality care where it happens.

Seddon wrote (1992):-

“Today we see organisations with bureaucratic administrative cultures into a bureaucratic administrative exercise….Valuable time is given up to feeding the quality management machine rather than getting on with improving things.”

The percentage of patients receiving poor quality care is not a number. It is people, suffering unnecessarily. Sending such numbers up to a Health Scrutiny Committee or Quality Surveillance Group is of no use if we don’t face up to the dis-integrated service provision causing each individual and personal crisis of care.

Why are these high level committees so incapable of helping us?

As one frustrated clinician put it:-

“We can see the crisis but not enough of those who can initiate the sorts of change required appear to be able to see it or perhaps they can but just don’t want to admit it?”

As someone who sits on strategic committees AND works at the coal-face, I think the problem is very hard to see from the stratosphere.

At LCC, we sit and scrutinise Red Amber Green rated documents that tell us which targets we are missing. We look at grand plans with excellent goals, objectives and perfectly plausible principles. But the ‘oily rag’ moment that should translate these visions into practice doesn’t happen. In organisational theory, this is known as ‘decoupling’. Decoupling happens when the stakes are high. There is a political imperative we must be seen to comply with. But in reality, achieving the goal set before us is nigh on impossible. We shuffle the papers, build another committee and keep looking busy in the hope the problem will go away.

At the top, there is a genuine belief that integration can be made to happen. Around the table, politicians hear leaders of all the organisations saying all the right things. Who are we (as mere elected members) to question the judgement of these experienced clinicians and professionals?

Dr Aled Jones (Cardiff University) came to give a Leicester University SAPPHIRE seminar in March, entitled ‘Are organisations silent or deaf when employees raise concerns? Reflections from a study of employee whistle-blowing in health and social care’. He referenced work going back to 1976 when Barry Turner coined the term ‘Failures of Foresight’ – giving evidence that most disasters are preceded by long incubation periods.

There are lots of reasons why those on the bridge don’t hear the voices of those in steerage who are screaming ‘mind the iceberg!’ One of them, in my unevidenced opinion, is about the nature of evidence. What gets people to move (motion) is feelings (emotion). We are moved by stories. Numbers leave us cold. By the time concerns about quality and safety get through the bureaucratic layers to the decision makers, they have been stripped of narrative.

As clinicians, we are troubled by confidentiality – and this can be used – by those who do not want to hear how bad it is – as a tool against us. If we strip all the clinical material out of an audit report it becomes as dull as ditchwater and is only fit to be thrown into the long grass.

Another barrier is our own culpability and professional guilt.

We need real stories to get up the agenda – but that means working with real people who have been let down, feel angry, confused and upset.We need, ourselves, to be able to hear and share these stories without being defensive. We are all part of this system and its failures. None of us can say ‘it wasn’t me guv’. We can’t blame UHL or LPT or Social Care or ‘bad GPs’. We are all involved. If we hide these stories – hoping to protect our health community from media embarrassment – we perpetuate a broken system.

In Total quality management ‘every defect is a treasure’. We need to get this kind of information discussed openly so that every failure becomes the impetus for ‘Better Care’.

 

This first appeared on Dr Eynon’s blog

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