In my introductory piece to this series of posts “The Mechanics and Morality of Change in the NHS” I identified six themes that I believe any innovator needs to consider before, during and after the process of introducing change to the NHS. (New readers may want to read that first).
Working through the unexpected consequences of change
To start with the problem of stopping.
Changemakers will recognise that some parts of the NHS don’t find it easy to institute change and innovation! Those of us arguing for change usually find it necessary to attend many many meetings arguing for change. It never easy to get change going. However, my initial point in this post is that whilst it always seems very hard to get an innovation going, it’s much harder to stop if it’s not working.
This may seem an odd place to begin but, bear with me, it’s all linked. Because it’s so hard to get going, because you have to ask permissions from so many people to get started and because you have to make your case for what you are going to achieve so many times, it is almost impossible to believe, when at last you get going, that your innovation won’t work. And so, when it doesn’t it’s so very hard to stop.
Yesterday I made the point that much secondary prevention work is based on the belief that it will save resources in secondary care. Some new services are set up to do that. But when the money is not saved, and since the new service feels pretty good in any case, it seems wrong to stop it.
The results of this tendency toward rarely stopping things are problematic.
One way of understanding the NHS is as a set of geological layers one laid upon another The third one down was meant to replace the fourth one down but never really got around to succeeding with that. So, the fourth one down is still there. The second one down was meant to replace the third one but never managed to. Now there’s a suggestion that a new geological level will come in to replace the existing top one. It probably won’t, but never mind.
Because each new layer never really replaces the layer below it creates a mess. Sometimes it’s just a mess (I get letters, texts, emails, phone calls and now the result of Epic – a fifth mode of communication – telling me about appointments at the same hospital. I am sure each was intended to replace the previous one, but they just add to each other. And I’m sure that sometimes this is a mess that contains even more danger than a missed appointment.
One of the reasons this comes about is because we are so happy to get agreement to do something that we never stop it if it’s not really working. We really must learn to do this. Let’s have some criteria about what is planned to be achieved in year 1, year 2, and year 3 and if at the end of year 1 this hasn’t been achieved. Let’s stop it. This is tough but we need to be a bit more ruthless about success and failure.
The fact that we don’t do this already means that one of the main arguments against change – “We are already doing it” is probably always a bit true. Because the reality is that we are already trying to do many things and haven’t really stopped any of them, which may well mean that we are doing something that is in the same ballpark as your suggestion. So, my first suggestion of unintended consequences is to be brave enough to stop doing something if it’s not working.
In terms of unintended consequences (actually this is a bit intended) nearly every scheme that involves secondary prevention shifts some element of care that at the moment is the responsibility of an NHS professional, onto the responsibility of the patient and their carer. One of the aims of this whole shift is to increase the amount of health and health care being carried out through the agency of long-term condition patients themselves.
But the patient and their world is different for nearly everyone. Some are technologically savvy, some are not. Some live alone. Some do not. Some have no friends and family who can come pop in some do not. Some are ‘part of a community’ some are not.
This all adds up to a need to understand the existing capacity and capability of people to take on health care. Then once detailed, whether the attempts by the NHS to add to that capacity and capability will actually work. It takes a while for a primary care practice (or a hospital) to talk through the existing capacity and capability that exists within and around a person. But for a patient with a long-term condition, this information is as important as the medicines they are taking. Getting a clear understanding of how much a person is really on their own or has sets of relationships that can help them monitor their health is important information that the NHS needs. Adding to rather than subtracting from this capacity is important.
(Of course, this might be carried out well or not depending on the capacity of the NHS institution to deal with data. I recently had an operation and in the two weeks beforehand and on the day itself, I was asked a total of 6 times whether I smoked and what medicines I was taking. Each time the information was typed into the same IT system to be found nestling next to my replies to the same questions in a questionnaire I filled in 3 weeks before. Personally, I was pleased they were asking me at all – but once would have been better!)
So, information about existing capacity and capability is important before you suggest that a patient or their carer can take over an element of care that had been carried out by an NHS professional.
But also checking whether the way that you are attempting to increase their capacity or capability actually works is also very important. I have suggested in this set of posts that if a few minutes of every consultation with a patient with a long-term condition was spent adding to their capacity to self-manage this would considerably increase the resources available to the NHS.
But only if the few minutes actually works. Historically, the way the NHS has done this takes me back to my days of student protest. Because the NHS, just as I used to in 1968, had a great faith in leaflets. Giving a patient a leaflet suggesting the stop smoking or drink less or get out a bit more, does give the impressions of adding to their capacity. But it doesn’t really.
So, if we want – at the end of every consultation – for the patient, their carers and even their community to have more capacity to better self-manage the patient’s condition, then we need to know that the things we think we are doing to increase that capacity and capability, actually do so.
The actions we take to do that might, for example, make us feel good. That’s nice, but unless they increase the capacity of patients and others to better self-manage, it is not working.
My message today about working through possible unintended consequences is for the NHS in general, and clinicians in particular, to recognise that without an improvement in patients’ capacity, in terms of this work, not a lot will happen. We will think people can better self-manage, and they won’t be able to.
To succeed in this much of the NHS will have to move beyond its present comfort zone, out into the community and into the voluntary sector and work with those sectors to increase the power of organisations that help build community capacity.
If over the next decade the new NHS model of care depends upon greater patient capacity to self-manage their care, we need to take an active role in making that really happen and not just to play at it.