Chris is Chief Exec of NHS Providers.  This is their Influencing Strategy outline from their web site (see here for web link):

“NHS Providers’ policy development and influencing work is focused on promoting and protecting our members’ interests against a backdrop of a rapidly changing health and social care system, and an extremely challenging financial context.”

Their members include the vast majority of NHS Providers. It is the membership organisation and trade association for NHS acute, ambulance, community and mental health services that treat patients and service users in the NHS.

A health warning first. Roy Lilley’s Health chat at the Kings Fund with Chris Hopson had a health edge. Roy had managed to mangle an ankle by tripping out of a black cab in London. He crumpled in a heap. The taxi driver (“gawd bless ‘im”), said “how are you?    (not good) “Would you like me to take you to a hospital?” (yes). But I don’t think Roy expected him to charge £15 for the lift! ( maybe we are not blessing him as much now…..)

This means Roy was in pain. And tie less for the first time I can remember (watch the whole event here, if you want to – see if you agree with my biases:  see NHS Managers.net You Tube channel.)  I expected him to be even harsher in the cat and mouse game of this cosy chat.. It was as eviscerating as normal. And as ever, if you know Roy, he gives people a harder time if he likes and respects them, I think.

But I have to say, the way they were chatting was quite depressing. This was a week before the amazing election result / the predictable election result ( did you like that?). We talked money, staff, STPs, CQC, CCGs, and the fact that it was all going to hell in a hand cart.  There were lighter views. But, I remained depressed at the prospects for the NHS throughout the event.  And honestly? I don’t think we should be that fearful.  I will return, but just for once, I think I may have to give you far more of my ideas and views, if that’s OK, on top of the overview of the event.

We were in the midst of Election Purdah….which doesn’t really apply to the NHS itself, as Roy politely pointed out.  We have become more and more fearful of these sort of suggested rules, I worry for democratic debate.

Let’s look at the highlights:

1. STPs : are they damaged below the waterline already? There was a suggestion from Chris and Roy that the level of public connection and involvement was not at the right level to make it stick.  My view? Get it on Facebook, and Twitter and have public presentations from the people involved, and present it on periscope or google live, and just get the ball out there, not in the long grass.
2. Chris also talked about the fact that the NHS people themselves are doing a grand job. Roy interjected with Mid Staffs debacle having an long spectre hanging over everyone and everyone’s thinking still. Roy and Chris begged to differ over Foundation Trusts and runaway deficits in our NHS budgets. There feels like there may have been a lot of pressure to cook the books, prior to calling an election (surely not?). It does feel like there may have been ‘arms up backs’ to make things look OK. The first FTs seem to have been featherbeded with extra funding to make sure they worked.  And that sort of actuarial massaging is still occurring. My view? It’s healthcare, not a market.  And there really is no such thing as a free market.  From banking to the media, from oil to internet based organisations, the big control the little.  So let’s get the market out of healthcare in the UK.  But let’s add in business strategic thinking, otherwise we will never get spend under control. And everyone has to be involved and empowered. Except the politicians.  Set the budget yes, but get out of the way and let the people who do it, do it.
3. Safe staffing. Chris talked about the 8:1 ratio, and argued, rationally, that this may not be sensible in every ward, every acute mental health trust, or wherever.  He suggested that we should let the local experts sort it.  That is the people on the wards, and all who are hands on with the patients.  I agree.  Matron led organisations need to be the norm! Sadly, we may not have enough nurses for the matrons to make sure they have enough people to cover patient needs adequately and safely. Chris said national framework staffing levels should be a guideline.  Why is it legally set in California, said Roy….I’m unsure, personally…
4. Health education England have written that we may have a shortfall of 60 000 nurses. We still have over subscription for nurse training places, even though there are no Nurse Bursaries any more? (It is now 3 applicants per place, not 6.) Depressing bit came when both participants talked about the prospect of many European workers leaving for home.  I think this may change once Brexit gets less nebulous and we all know where we stand.  Why should it be really different than before we were in the EC?  I personally am very pro Europe, but anti EC…and I don’t think anyone knows what will happen.  Uncertainty though really doesn’t help long term planning.
5. Election Purdah raised its head again.  Roy tried to get Chris to come down in favour of one side or the other.  He played the ball straight back.  He said the only way to be sensitively influencing all sides equally was to be even handed. So Jeremy Hunt, Jon Ashworth and Norman Lamb were all involved.  As all could be involved post election…
6. We often talked about pockets of the NHS at the forefront of positive thinking and actions (Salford, Northampton, Northumbria, Frimley, Devon, and many more). Maybe we do just need to let the guys do it themselves? Just let them go, and do it?

Politicians don’t want us to use real evidence based reality to inform.  I would love PFI to be removed from all of Chris’s membership organisations day to day reality.  I bet this 2% of the whole budget occupies 50 % of management time in some Trusts?

There were many other interesting stats chucked into the conversation – have a look here…but if you want my two favourites, here they are.

Once we are 70, we start having the potential of increasing our demand on the health service.  We need to make sure the education on exercise and eating is inculcated from junior school.  We are living longer, but maybe less well?

70% of our lifetime healthcare costs come in the last 6 months of our lives.  Are we over medicalising death? Perhaps we need to start having the good death mentality, and let nature take its course – and save both dignity and money at the same time.

I think I still feel depressed at the negativity and extreme worry portrayed by both participants.  But madly, as a very annoying optimist, I want to let our amazing NHS teams be just that.  Teams.  Powerfully excited.  They need to be supported, thanked, enjoyed, celebrated and kept alive.  I think maybe Roy and Chris both feel that can happen, but will it be allowed to happen?

Politicians? Just leave them alone to get on with it.  I trust them rather more than I trust you.  And the NHS may well be ‘running hot’, but it is still running despite partisan politicking tinkering at the edges.

Thanks Chris and Roy.  You worried me. But made me think.

Henry Mintzberg, OC OQ FRSC (born September 2, 1939) is an internationally renowned academic and author on business and management. He is currently the Cleghorn Professor of Management Studies at the Desautels Faculty of Management of McGill University in Montreal, Quebec, Canada, where he has been teaching since 1968

Evening, Prof….

Ok – that’s the WikiPedia background.  Now onto meeting and listening to the man himself:

They say you should never meet your heroes, for fear of disappointment. I met Henry Mintzberg, erstwhile management thinker and writer during my OU MBA course, in print, and was always fascinated by his thinking. I was lucky enough to meet him in person at two meetings at The Kings Fund in London.  The first was under the auspices of The Institute of Healthcare Management – an intimate affair with lots of question space. The second meeting was an NHS Health Chat, with Roy Lilley interviewing Henry. (Film of the meeting available here)

I wasn’t disappointed.

Much of the Profs work has started out very simply. “All I did was get down on the ground and saw what was going on. Then just wrote that up.  My findings were always just the patently obvious, but no-one was doing that”.

Healthcare has always been part of his research interest.  His latest book “Managing the Myths of Health Care” is as provocative as the title suggests. Anything that says after just a few preliminary pages, that Health Care is not failing, but succeeding, expensively, and we don’t want to pay for it. So the administrations, public and private alike, intervene to cut costs., and therein lies the failure”.

His thinking is always nuanced, not in extreme ideological positions.  There is great debate on Globalisation in the worldwide political sphere as we speak.  It is black and white, good or bad, as far as most report their views.  Henry?  “I’m for and against it”. I needed to listen more closely ( and as with all my summary blogs of talks, I may miss things that you would hear differently. And I will allow my opinions to the fore. So, this is not a report, it is a view…).

The myths were discussed a lot in this chat. Especially the ‘not failing’ view, but just succeeding expensively. The chat then veered into how organised or not organised health care is.  With the rejoinder that it is very easy to reorganise for short term patch up of problems.  Anyone can do that.  The book then goes onto how do we reframe the whole.

Henry with Simon Stevens, NHS England

His stories and observations drive his thinking and opinions.  More than for most of us. And he is still learning. Outsiders can give some ideas, but insiders need to drive change.  Budget constraints provide focus, sometimes.  Those in middle management can feel constrained and demoralised (ain’t that the truth!). Quotes abounded too.  “If you have responsibility, you don’t need accountability”.  He made the case for looking for causes (whether problems in an institution, or a health care issue), rather than cure.  In the main, I agree.  We still have a National Sickness Service in the UK.  Health promotion is in the mix, of course, but always feels like the poor relative.

Fascinating tangent on measurement: in his hometown of Montreal he asked his local hospital chief why they measured so much?

“What else do you do when you don’t know what’s going on?”.

We’ve all heard paralysis by analysis…and Henry’s line was a chapter title “Analysis:analyse thyself”. My line is “You can disappear up your own analysis”. And, another favourite, “you don’t fatten a pig by weighing it”.

What is efficiency? As soon as you use a word like that, it isn’t neutral.  We measure what is measurable.  I think we measure what is easy to measure, distorting what is not measurable.  It may mean we cheapen what is really important.

Good enough, or World Class? Best, in a competitive situation, may not be good enough. Too low a standard, as prof said! Good may be your best.  Every person to be their best? Is that how we get to being more than good enough?

And what vehicle to make that happen? Collaboration, versus self interest, may be easy to say.  He talked of Communityship, a refocus on society.

In the evening session, softly interrogated by Roy Lilley, we learnt a bit more about why Prof Mintzberg was so against ordinary MBA programmes.  (A show of hands proved a good 25% of his audience were MBA graduates). “Wrong people taught the wrong things at the wrong time.  You don’t learn to swim in a classroom”. Most of the grads there were mature students originally, so that takes care of wrong people wrong time.  But I agree with the supposition that function expertise can be learnt – marketing, strategic planning, finance – but not hands on people skills.  University of life for that, I feel. His triangle of Art, Science and Craft, standing for people and soft skills, analysis, and expertise, rang true for many. To improve the selection of managers, he suggested those they have managed before should input into the process.  Blindingly obvious, but rarely done?

Simplifying the message was a core theme repeated often by the Prof.  So I will do the same:

1. Why do we obsess about data and analysis? We only measure what is easy to measure, not what is truly important.
2. Stories and anecdotes are your company culture
3. Remote control management fails, every time, over hands on, getting down on the floor
4. Management is what we do. He is not a fan of leadership (Hurrah….I always fell out with the writings of Warren Bennett over this.  We all do both.  One isn’t better than the other).
5. Everyone has something to input. Hierarchy can stifle that.

Finally he said that Healthcare is a calling, not a business.  If we can just do that, with everyone aiming to think how can I get better at my job today, and keep the crass business models out of Health, then we can let Communityship flourish.

Just a final thought.  US healthcare costs 11.5% of GDP.  U.K. is 6.3% – and is universal.  Just experienced the NHS at its best at a minor injuries unit in Tewkesbury, on a Sunday. Triaged and fixed in 45 minutes.

I know where I’d rather live.

Helen Stokes Lampard

“It was a fair fight for the position. Four candidates. I won.”  We expect Roy Lilley’s chats to be rather more combative than fireside, but that was a fairly typical response from Helen.

Not only chair of the Royal College of General Practitioners, but one day a week partner in General Practice in Lichfield, And in her spare time, Governor of the Birmingham Women’s NHS Trust.

Where did it start? A penchant for science, led by role model who was dad, in Swansea who taught science. Excited by Dentistry, through another role model who she stayed with one long vacation. She made the job sound very enticing. (Funny how a lot of role models and influencers are passionate about their work…). Salutary first underachieving at A levels was a useful life lesson, and St Georges beckoned after the second attempt. “Why not Welsh medical school?” “Family would have loved it, but as a teenager, I wanted to be far away!” House jobs through a swap, back in Wales.  Then a fun serendipitous turn of events….a penchant for research led to a PhD (so a proper Doctor!), which changed gynaecological screening in the UK. This led to joining an unusual (but shouldn’t be?) training scheme.  Half GP trainee, half academic research.  Then later in Birmingham, added in learning to teach soon.

I only give all the background because it does inform the view of the person, and how they have got there.  Although this is always my personal opinion, you can watch the whole interview free, clicking on here for the NHS Managers.net YouTube channel.  But I really got Helen’s passion, drive, intelligence and vision. Motto of the RCGP was repeated a few times. “Scientific knowledge applied with compassion”. Anyone can trot out platitudes, but I got the feeling she not only meant it, she lived it.

As ever, we learnt as much about Mr Lilley’s foibles as the chatee…”Why women’s hospital…we don’t have men’s….”  “What about getting me an old geezer GP – I’m not seeing a woman!”.  Then a bit more banter level “You fell out with the builders at the new office, 30 Euston Square?” “And we won the dispute”. I was really enjoying the instant replies.  NHS was castigated as a non family friendly employer.  Crèche spaces as rare as rocking horse droppings.  This moved us nicely onto that nights publication of the RCGP manifesto – out long before the political parties have managed theirs for the election.

The theme and main thrust of the evening was around is General Practice about to wither away? A simplified 6 part plan to save the NHS loomed over the audience (embargoed until midnight that night, but we kept getting sight of it as Roy continued to be naughty!).

(You can see the Manifesto here)

The election should not just be about Brexit.  The entire population needs healthcare. And everyone has a story, opinion and bias about “our NHS”. Here’s my notes on the 6 steps to save the NHS.

1. Fund primary care so the GP 5 year forward view can be delivered
2. Support euro and overseas employees, healthcare and allied professions.
3. Extend GP training to 4 years from 3. They are “expert medical generalists”, and the job is more complex than ever. Cheaper in long term.
4. 5000 more GPS by 2020
5. A new return to work initiative for nurses, mental health professionals and pharmacists to join the multi faceted teams needed for evolving general practices
6. Sort out the spiraling costs of GP indemnity insurance – yes, if mistakes happen, sort it, but not ambulance chasing.

See the whole here, but I like the simplifying.

70% of NHS costs are people.  We cannot just make the savings asked for from efficiency of the 30%.

What else for the future?  More remote consultations? Maybe it has to be “good enough” for some situations? I do feel one size doesn’t fit all.  And we all have different needs for different conditions  ( notwithstanding maggots in the scrotum, which Roy quoted twice, from Mormon a west end musical…don’t ask…). Maybe Skype, or apps like Babylon, or Face Time, or just the mobile phone, or near patient testing can help some people sometimes? Best quote of the night ? Roy: “There’s no silver bullet here, but maybe there is silver buckshot”. Primary Care Home is being successful in some places.  Sustainability and Transformation Plans (STPs) occasionally left GPS out of the solution – until hospitals told some of the local planners not to be daft. We do need to grow the wider GP team.  We do need the holistic approach of Primary led, secondary fixers and social care support to become fully dovetailed and smoothly transitioned. There need to be more new ways of working, and GPs tend to be active early adopters.  It feels like Helens vision around recruiting, retaining and returning of all the allied healthcare professional teams will help drive it all forward rather than over a cliff.

Some other great ideas about social prescribing, the tripod of social care, primary and secondary care, GP in A & E, other folk appropriate to the patient need (paramedic in out of hours triage, for example).

It was an evening full of hard hitting practical do-able ideas that were not scary or mad or just talk.  It feels like we just need the powers of persuasion to make the talk stop and the action start.  Helen Stokes Lampard is highly persuasive innovative and very hard to ignore.

Whoever wins the election, please be aware she will come knocking…and won’t take no for an answer.