The sea reflected the almost unblemished sky with a dark, angry meridian blue. Only the slate-grey streak above the horizon belied the otherwise benevolent August day. The rocky outcrops, punctuated by deep black caves and lightly rusted with seaweed and lichen, glistened like tarnished silver in the midday sun. The mineral white surf thrashed with frenzied futility against the oblique buttresses of rock, throwing up foamy spray that blew about like a midsummer blizzard. Occasionally it would drift up over the cliff edge to the vivid green fields capping the headland, dotted with sheep chewing with bucolic nonchalance, oblivious to the seething battle only feet beneath them.

The Atlantic rollers were splendid, coming with just the right periodic regularity, energised by the residuum of a distant hurricane reverberating it’s destructive existence from across the ocean three days before. Standing with my surfboard each wave announced it’s arrival at first with a powerful sucking force, dragging sand, seaweed and debris painfully around my legs. It would then rear up, a sandy turquoise colour latticed with submerged foam, darkening suddenly as it tipped into a breaking roller. If I timed it right it would pick me up and accelerate me forwards dangerously, exhilaratingly, thrilling in a way no cosseted roller coaster ride could possibly ever achieve.

They just kept coming and I couldn’t drag myself away – addicted to the reliable adrenaline rush with each wave I caught. I must have not stopped to look around for some time because all of a sudden the sun winked out, engulfed by the dark grey blanket that had scudded in from the horizon. The mood of the waves turned from playful energy to menacing power and my anticipation became tainted with anxiety.

I staggered with the drag as the water level dropped from mid chest to below my knees. This wave really towered, it was clouded with the churned sand in it’s turbulent core and seemed to suspend itself above me whilst I decided whether to dive through or try and catch it. Of course it was playing with me, laughing at me, as I decided a fraction of a second too late to try and catch it. I felt the weight of the water first – it crushed the air out of my lungs – before picking me up and turning me over feet first, tearing the surfboard from under me and snapping the wrist tie. I was submerged and tumbling, the force of the water pushing me face first into the gritty sand, before changing direction and picking me up again. I couldn’t breath and sandy salt water was forced into my nose and throat. It kept me under, shaking with contempt my rag doll attempts at swimming, long enough for the panic of imminent drowning to start rising from my solar plexus. Just as I began to think I couldn’t get out of this it dragged me front first into the shallow shore, sand filling the front of my wetsuit. The water hissed as it retreated away from me over the rippled sand, as if to dare me to try this again.

I limped up the beach with my broken surfboard flapping forlornly, bruised, grazed and my head spinning slightly. I lowered myself on to the picnic blanket to a welcoming sweet biscuit and strong coffee as the light summer drizzle began to fall.
“How is the surfing today darling?”
“Brilliant – absolutely brilliant…”


In a book chapter I wrote on the subject of information management in critical care, I concluded that one of the most important challenges for this generation of doctors is the transfer of clinical information management from paper to electronic systems. So far we have failed that challenge, the vast majority of clinical information is still being recorded and managed (rather poorly) on paper. Those parts that are managed electronically are, in general, still cumbersome, bespoke systems that serve functions other than the delivery of clinical care far better than the needs of doctors, nurses or even patients. As a result a lot of these systems are at best grudgingly tolerated, often despised and sometimes even avoided altogether. The majority of doctors, with the exception of the minority enthusiasts, have withdrawn from the conversation on development of information management systems (or even been left out altogether) because it has been seen as a technological challenge rather than a clinical one. This is wrong and has to change because the way we manage clinical information is a crucial enabler for radical change in health care delivery. If doctors fail in this challenge we will find ourselves marginalised and obsolete in an ‘innovatively disrupted’ health economy.

Early Adopters

There is, of course, some history here which partly explains our current situation. Electronic clinical information systems have been in existence for over twenty years. The early years of the development of these systems was dominated by the technological challenges. The sheer volume and complexity of information that is collected in the course of delivering clinical care was a challenge when the cost of electronic storage was high and networking infrastructure not well developed. Taming the complexity of the information – codifying it and structuring it so that it could ‘fit’ in a conventional database – was not only difficult but also met with resistance of professionals as it constrained practice and the PC / workstation became a barrier between doctor and patient. Despite these challenges there are examples of hospitals and hospital systems that showed the world how it could be done (Burton Hospital being a notable example in the NHS) and also how it could go wrong.

The Lost Decade

If the nineties was the pioneering decade for clinical information systems then the first decade of this century can only be characterised as the ‘lost decade’ – whilst the Internet flourished and the age of distributed, personalised, world-in-your-pocket computing dawned – hospital IT systems remained desk-bound, cumbersome, inflexible, centralised systems. The need for information sharing was misinterpreted as a need to provide a single solution for all. A strategy that has cost billions, failed to deliver and diverted funding and more importantly the engagement of the medical profession (it was often doctors with IT skills that where the pioneers of the early adoption period) away from user and patient centred solutions.

A Tablet Ushers in a New Era of Medicine

Technology is no longer the problem – storage is cheap and abundant, networks are reliable and fast and devices are powerful, intuitive and mobile. Data management has transformed as well. XML allied to sophisticated search algorithms means less taming of information is required, the structure of the ‘database’ need not trouble the user any longer. Cloud technology means that information can be kept absolutely secure whilst not compromising the freedom of permitted users. The technology really has come of age and has surpassed the specification required to deliver clinical information management that truly serves the needs of patients, doctors and managers. Mobile devices like the iPad can give doctors both tools for information gathering and the tools to access it when it is needed without the technology getting in the way of the transaction with the patient.

Paper, Paper Everywhere!

But we are still using paper – tons of it. Medical records are stuffed with cardboard folders bursting with, mostly useless, pieces of paper. The information is locked away, unstructured and inaccessible – every request for information (and there are lots) is a mountainous struggle, consuming hundreds of man hours to extract it. The functions of the paper medical record as care coordinator, communicator, clinical process manager, monitor and legal witness are all conflated and result in an extreme precautionary approach to the retention of information which completely subsumes the probably more important function as informant almost as important (and often more informative) as the patient themselves.

It’s the Information Stupid

It’s time for the conversation to move from the technology to the information. We must focus on the type of information we gather, how we gather it, what we need and when we need it in order to deliver safe effective care. So much duplication and iteration and re-iteration of clinical information has evolved as a defence against the in-accessibility to information. Most patients I have met are astonished at the number of times they are asked the same questions over and over again even within the same clinical episode – they see the duplication and fragmentation that we as professionals miss.

The care we give our patients is complicated and messy – partly because our patients are complicated and inflict on us huge variance in presentation, severity, comorbidity and response to treatment. That is the nature of medicine and what makes it so all consumingly interesting. But we make life exponentially more difficult for ourselves by imposing our own variance in practice and reliability on this already unpredictable background. Doing it differently every time, sometimes even changing our mind half way through results in variance on variance which is the definition of chaos. Chaotic medicine results in unpredictable, usually poor, outcome and huge waste – and is bad medicine.

There is an answer to the information problem which also solves the chaos problem and results in not just better care but dramatically better care. Healthcare organisations that adopt this solution are not only better than their peers they are exponentially better. The solution is the key to delivering reliable care and it is the Clinical Process Model. This will be the subject of my next blog.

It is interesting to reflect – now that the PFI bonanza has come to an end and we all have to hunker down and work out how to pay for it for the next 30 years – on what we have spent all the money on and consider whether what we have thrown up around the land is actually what we need.

This paper by the think tank Reform The Hospital is Dead Long Live The Hospital is an eloquent exposition of Clayton Christensen’s ‘Innovator’s Prescription’ within an NHS context. The essential conclusion of both of these is that Hospitals need to move from being ‘A place where sick people go’ to becoming ‘An organisation that keeps people well’. This re-framing of purpose prompts the question – what does a hospital that keeps people well look like? I suspect it is not a large building with lots of beds in it (or clinic rooms for that matter).

Interestingly the specialty of Intensive Care Medicine underwent a similar re-framing of purpose over ten years ago as a result of the comprehensive critical care program in response to a lack of intensive care beds. The outcome of this process was the introduction of critical care outreach teams (or medical emergency response teams) linked to a system of population surveillance (MEWS track and trigger) and an expansion of lower acuity beds (high dependency). There were almost no additional intensive care beds commissioned or provided. The result has been intensive care units have been able absorb ten years of demand growth, almost eliminate the need for inter hospital transfer for capacity reasons, reduce futile care, contain costs and improve outcome.

How do we replicate this operating model at the scale of the hospital within a health economy (as opposed to an intensive care unit in a hospital)? The essential elements are:
1) Knowing the population you are caring for – a disease registry
2) Knowing how they are – a simple method of measuring disease status
3) A response team that averts crisis when a trigger threshold is reached – a specialist community team
4) An escalation pathway that includes rapid access to specialist input – specialty hubs
5) Lower acuity beds for step up or step down care – intermediate care beds
6) Alternate pathways for those that acute care is inappropriate – end of life services
7) Acute beds for those that genuinely need it – closely linked to an intensive care unit!

This distributed model of care does still need buildings – but what it needs more is intelligent information and communication systems used by a workforce that understands the need to keep patients other than those in genuine need away from hospital. It also needs an operating system that measures its impact, analyses unexpected pathway deviance and learns from system failure.

Eliminating the huge waste in the system of inappropriate and futile hospital care (both inpatient and outpatient) will not only deliver cost savings it will improve quality of care and outcomes and create the capacity we need for the growth in demand we know is coming.

The hospital is no longer a building it is a healthcare delivery system. We should be investing in the infrastructure that makes it possible – And that is not bricks and mortar…

In my last post I described my journey to taking the decision to become a medical director. I know that many of my colleagues, whilst being extremely generous in their congratulations and sincere in their wishes of good luck and fortune – may well be thinking along the lines “why would you do that?”. I know that is what I thought for quite some time, and a bit of me still does…

The Cost

The loss of clinical practice is the first barrier – it has direct cost to the individual doctor. Earning opportunities for supplementing ones basic NHS salary as a practicing clinician are legion, waiting list initiatives and private practice if pursued with dedication and vigour can easily surpass even a medical directors salary. As one becomes more and more embroiled in the maelstrom of medical leadership the loss of time (and vigour!) gradually closes off these opportunities – the arcane pay structures of the NHS are peculiarly bad at rewarding those that do choose to take that path; and when they do it results in a wholesale pillaging of ones pension by the tax man (that alone is enough to put many off).

Most doctors though are not wholly motivated by money (fortunately) – but there is a deeper and more personal cost to moving away from clinical practice and that is the less tangible but very real issue of status. The status of medical practitioner is hard earned but once achieved is gratifyingly well rewarded. Doctors are accorded a great deal of authority and privilege both within and outside the work place – with that comes much expectation and responsibility. One’s status as a trained practitioner in your chosen specialty, the time and effort put in to achieving it and the rewards it brings through the gratitude and respect of patients, colleagues and society results in it becoming an embedded part of one’s identity – giving it up is giving up a part of yourself and replacing it with….management (why would you do that?).

Now I’m not saying that becoming a medical director will result in a wholesale loss of status nor for that matter will I be impoverished by the move. Nevertheless I am giving up part of my identity (in my case I am giving up intensive care medicine), I am stopping doing something that on a good day is actually good fun, I am leaving behind colleagues and friends (who no doubt think me very disloyal) and replacing it all with a new and different status – one with uncertain benefits and certain risks.

Certain Risks

There is no doubt the climate is harsher the higher you climb the leadership pyramid (for the record I’m not a fan of hierarchical metaphors for leadership structures with all the value laden implications of rank – common usage though makes them hard to avoid…). Scrutiny is more direct, more personal and less forgiving. Failure is overt, public and consequential to one’s job. The safety net of return to clinical practice gets thinner and the holes bigger the more time you spend away from it. Exit strategies are unclear, career paths poorly defined, training and support hard to find (expensive when you find them). These are realities faced by almost anyone in positions of responsibility both in public and private sector organisations. The wind only feels chillier to a doctor because of the remarkably secure, well rewarded and unassailable position that being a consultant is.

Uncertain Benefits

You are paid more – though the pathway through clinical directorship and associate medical directorship on your way there is hardly littered with gold. Most Trusts struggle to release the time let alone the money to encourage doctors down the path – certainly insufficient to compensate for the opportunity costs outlined above. Your salary is a matter of public record and subject to scrutiny in a way no other consultant has to endure. Should this discourage you? – Absolutely not, the money is good enough that for the vast majority of us it is a non-issue, it’s ‘off the table’. The role brings a level of autonomy, self determination, sense of purpose and opportunity for personal development that no other leading to it can – for me this is the motivation.

So would you do it?

It doesn’t stack up well – and there are lots of things we could do to make it stack up better. Many outlined in this report. I am certain there are many doctors out there with the leadership skills that are needed that are reluctant to put themselves forward. My advice is take the plunge, change is good.

On the 1st of August 2012 I will be taking up the post of Medical Director at a large NHS Trust in the Midlands UK.

This blog is an outline of my journey to this critical juncture of my career and I intend to use it to share my experiences in this role and I hope to help others – either actual or aspiring medical directors – in their journeys too.

It is my belief that too few doctors put themselves forward for leadership and management positions in healthcare in general and the NHS in particular. Having made the plunge – I understand why and want to use my insight to support others in following me. My motivation is that I genuinely believe that without active engagement of and leadership by doctors the quality and safety of the service we provide is significantly threatened by the current and ongoing funding crisis. Only doctors have the insight and knowledge that equips them with the skills to make the really hard choices involved in balancing cost and benefit. However to put themselves in a position where they can make those choices in a way that makes a significant difference to large numbers of patients at a scale that also makes a significant difference to the cost of delivering healthcare to the economy requires individuals to make real sacrifices.

My Journey

I am by training an anaesthetist and intensivist. I became a consultant in 2002 and within 2 years found myself clinical director of critical care services in one the of the largest acute trusts in the NHS – operating out of three acute hospitals. This wasn’t because I was ambitious to do so, or even envisaged myself doing that role when I was appointed, it was simply because no one else wanted or was ready to do it (neither was I). My first year as CD I had no directorate manager, I had no training but I did have a fantastic team of senior nurses and consultant colleagues willing to work together as a team. Over the subsequent 5 years I had 6 different directorate managers working with me, some excellent others less so – and therein lies one reason why we should not leave radical reform of services to non-clinicians; only doctors and nurses are in it for the long haul, managers by their nature move on, and don’t always witness the consequences of their actions.

I am lucky to have trained and worked in a truly modern specialty – one that recognises the necessity of team working, that sees doctors, nurses and other healthcare professionals as equal partners in that team delivering an outcome for the patient – one that recognises the need to take control of the whole cycle of care including the pathway to the door of the ICU (through MEWS and critical care outreach) – one that recognises the need to codify and simplify the process of care delivery in order to improve reliability (through care bundles – checklists by another name) – one that recognises the need to measure risk adjusted outcome and use it to continuously improve the service (through ICNARC). Ten years or more of this approach has resulted in an un-sung triumph of healthcare – the virtual elimination of central venous catheter related sepsis, the placing of sepsis in general at the top of the emergency medical agenda, year on year reductions in mortality (our SMR has fallen from 1.3 to a low of 0.73 just before ICNARC re-calibrated the risk model). This is not a unique success, it has been replicated in intensive care units across the country and the world.

I recognised that there are some generalisable principles in the critical care story that if applied across a healthcare economy could bring about radical improvements in the quality of care delivered at the same time as reductions in the cost of care. This belief motivated me to not only learn more about models of healthcare delivery and their practical implementation but also to put myself in a position where I could influence – rather than remain a frustrated observer. It struck me that not only is this an area of fulminant intellectual activity, it is also an area where as an individual one can make more difference to more patients in a shorter space of time than any area of academic medicine (I am after all an archetypal anaesthetist – an impatient physician!).

These thoughts (not necessarily as well formed at the time) led me to apply for the position of associate medical director at my Trust (in 2009), and also to the hallowed halls of Harvard Business School (in 2010/11) where I was exposed to the global cutting edge of thinking in healthcare delivery. This experience has been transformational for me personally, affirmed my belief that this is the right career path for me, and equipped me with knowledge and insights that I am impatient (again) to see put into practice. Many of the ideas will be themes I will draw out in future posts. The time is right – new ideas are becoming established in the thinking of policy makers – integrated care, outcomes frame works, value based competition, improvement science – and the need has never been more urgent.

And so here I am in 2012 about to take up MD post at another large trust. In my next post I will talk about why many wouldn’t do what I have done and why I nearly didn’t…