I attended the recent ‘Digital Health Re-Wired’ conference at Birmingham’s NEC last week. There was a lot of talk about AI – in fact I think the term pretty much featured on every stand and in every stage presentation at the conference. People are excited about AI and wherever you work in healthcare AI is coming to a clinical information system near you…

At this point I need to declare an interest – I absolutely hate the term Artificial Intelligence – I think it is a totally misleading term. In fact I’m pretty sure that there is no such thing as artificial intelligence – it is a term used to glamorise what are without doubt very sophisticated data processing tools but also to obscure what those tools are doing and to what data. In medical research hiding your methods and data sources is tantamount to a crime…

An Intelligent Definition

So what is artificial intelligence? It refers to a class of technologies that consist of certain types of algorithm paired with very large amounts of data. The algorithms used in AI are variously called machine learning algorithms, adaptive algorithms, neural networks, clustering algorithms, decision trees and many variations and sub-types of the same. Fundamentally however, they are all statistical tools used to analyse and seek out patterns in data – much like the statistical tools we are more familiar with such as linear logistic regression. In fact the underpinning mathematics of a learning algorithm such as a neural network was invented in the 18th century by an English Presbyterian Minister, Philosopher and Mathematician – The Reverend Thomas Bayes. Bayes’ Theorem found a way for a statistical model to update itself and adapt its probabilistic outcomes as it is presented with new data. The original adaptive algorithm – which has ultimately evolved into to today’s machine learning algorithms – which are given their power by being hosted on very powerful computers and being fed very very large amounts of data.

The other ingredient that has given modern machine learning tools their compelling illusion of ‘intelligence’ is the development of a technology called large language models (LLMs). These models are able to present the outputs of the statistical learning tools in natural flowing human readable (or listenable) narrative language – i.e. they write and talk like a human. Chat-GPT being the most celebrated example. I wrote about them about 5 years ago (The Story of Digital Medicine) – at which point they were an emerging technology but have since become mainstream and extremely effective and powerful.

Danger Ahead!

Here lies the risk in the hype – and the root cause of some of the anxiety about AI articulated in the press. Just because something talks a good talk and can spin a compelling narrative – doesn’t mean it is telling the truth. In fact quite often Chat-GPT will produce a well crafted beautifully constructed narrative that is complete nonsense. We shouldn’t be surprised by this really – because the source of Chat-GPT’s ‘knowledge’ is ‘The Internet’ – and we all have learned that just because its on the internet doesn’t mean its true. Most of us have learnt to be somewhat sceptical and a bit choosy over what we believe when we do a Google search – we’ve learnt to sift out the ads, not necessarily pick out the first thing that Google gives us and also to examine the sources and their credentials. Fortunately Google is able to give us quite a lot of the contextual information around the outputs of its searches that enables us to be choosy. Chat-GPT on the other hand hides its sources behind a slick and compelling human understandable narrative – a bit like a politician.

The Power of Data

In 2011 Peter Sondergaard – senior vice president at Gartner, a global technology research and consulting company – declared “data eats algorithms for breakfast”. This was in response to the observation that a disproportionate amount of research effort and spending was being directed at refining complex machine learning algorithms yielding only marginal gains in performance compared to the leaps in performance achieved by feeding the same algorithms more and better quality data. See ‘The Unreasonable Effectiveness of Data

I have experienced the data effect myself – back in 1998/99 I was a research fellow in the Birmingham School of Anaesthesia and also the proud owner of an Apple PowerBook Laptop with (what was then novel) a connection to the burgeoning internet. I came across a piece of software that allowed me to build a simple 4 layer neural network – I decided to experiment with it to see if it was capable of predicting outcomes from coronary bypass surgery using only data available pre-operatively. I had access to a dataset of 800 patients of which the majority had had uncomplicated surgery and a ‘good’ outcome and a couple of dozen had had a ‘bad’ outcome experiencing disabling complications (such as stroke or renal failure) or had died. I randomly split the dataset into a ‘training set’ of 700 patients and a ‘testing set’ of 100. Using the training set I ‘trained’ the neural network – giving it all the pre-op data I had on the patients and then telling it if the patients had a good or a bad outcome. I then tested what the neural network had ‘learned’ with the remaining 100 patients. The results were ok – I was quite pleased but not stunned, the predictive algorithm had an area under the ROC curve of about 0.7 – better than a coin toss but only just. I never published, partly because the software I used was unlicensed, free and unattributable but mainly because at the same time a research group from MIT in Boston published a paper doing more or less exactly what I had done but with a dataset of 40,000 patients – their ROC area was something like 0.84, almost useful and a result I couldn’t come close to competing with.

Using AI Intelligently

So what does this tell us? As practicing clinicians, if you haven’t already, you are very likely in the near future to be approached by a tech company selling an ‘AI’ solution for your area of practice. There are some probing questions you should be asking before adopting such a solution and they are remarkably similar to the questions you would ask of any research output or drug company that is recommending you change practice:

  1. What is the purpose of the tool?
    • Predicting an outcome
    • Classifying a condition
    • Recommending actions
  2. What type of algorithm is being used to process the data?
    • Supervised / Unsupervised
    • Classification / Logistic regression
    • Decision Tree / Random Forrest
    • Clustering
  3. Is the model fixed or dynamic? i.e. has it been trained and calibrated using training and testing datasets and is now fixed or will it continue to learn with the data that you provide to it?
  4. What were the learning criteria used in training? i.e. against what standard was it trained?
  5. What was the training methodology? Value based, policy based or model based? What was the reward / reinforcement method?
  6. What was the nature of the data it was trained with? Was it an organised labeled dataset or disorganised unlabelled?
  7. How was the training dataset generated? How clean is the data? Is it representative? How have structural biases been accounted for (Age, Gender, Ethnicity, Disability, Neurodiversity)?
  8. How has the model been tested? On what population, in how many settings? How have they avoided cross contamination of the testing and training data sets?
  9. How good was the model in real world testing? How sensitive? How specific?
  10. How have they detected and managed anomalous outcomes – false positives / false negatives?
  11. How do you report anomalous outcomes once the tool is in use?
  12. What will the tool do with data that you put into it? Where is it stored? Where is it processed? Who has access to it once it is submitted to the tool? Who is the data controller? Are they GDPR and Caldecott compliant?

Getting the answers to these questions are an essential pre-requisite to deploying these tools into clinical practice. If you are told that the answers cannot be divulged for reasons of commercial sensitivity – or the person selling it to you just doesn’t know the answer then politely decline and walk away. The danger we face is being seduced into adopting tools which are ‘black box’ decision making systems – it is incumbent on us to understand why they make the decisions they do, how much we should trust them and how we can contribute to making them better and safer tools for our patients.

An Intelligent Future

To be clear I am very excited about what this technology will offer us as a profession and our patients. It promises to democratise medical knowledge and put the power of that knowledge into the hands of our patients empowering them to self care and advocate for themselves within the machinery of modern healthcare. It will profoundly change the role we play in the delivery of medical care to patients – undermine the current medical model which relies on the knowledge hierarchy between technocrat doctor and submissive patient – and turn that relationship into the partnership it should be. For that to happen we must grasp these tools – understand them, use them intelligently – because if we don’t they will consume us and render us obsolete.

As a medical director of a large acute hospital trust, how people die in our care occupies quite a lot of my waking thoughts (and quite a few of my sleeping ones too…). I thought I knew quite a lot about this subject – coming into the role from a background of critical care (where death is common). I have found though that my experience, whilst a useful primer in the topic, has demanded significant additional learning on my part – this post is my attempt to share some of that learning.

People Die in Hospital – That’s what they do

There is a curious symmetry in the social changes that have occurred at both the beginning and the end of life. The realisation over the last half century or so that many of what were believed to be inevitable tragedies at the beginning and end of life were in fact amenable to technological intervention and thus avoidable – and the change in the medical profession from overseer and commentator of natural tragedy to intervener and preventer of such – has driven these life events from a home based setting managed by community based services into a hospital setting managed by doctors, nurses and midwives.

This is largely a good thing – more mothers and babies survive the traumatic vagaries of child birth than ever before and people live longer healthier lives than ever before.

There is one rather stark asymmetry though – whilst death and tragedy in child birth is now a very rare event indeed – death at the end of life is still ultimately inevitable. As a society, even though we know we have to die eventually, we still haven’t worked out how we should die. This means that the majority of people end up dying in hospital (over 50% of people – thanks to Shaun Lintern and Craig Stenhouse for correcting this for me!) with doctors and nurses trying to stop them from doing so even when death is inevitable.

This is not a good thing because dying with someone trying to stop you with all the technological weapons of modern medicine (however well meaning) is not a good way to die.

The alternatives – provided by the heroes of the hospice movement – remains a cinderella service, patchily provided, reliant on charity and sparsley funded by public money.

Avoiding the Unexpected

So, people die in hospital – in our two hospitals that is about 1600 people a year (about 1 in every 75 admissions or put another way 4 or 5 admissions every day don’t make it home alive).

When these deaths are studied they can broadly be categorised into three groups according to whether they are expected or unexpected deaths and avoidable or unavoidable deaths.

Category 1Unavoidable expected deaths. This is overwhelmingly the largest category of deaths in hospital. People reaching the end of their natural lives, where their frail bodily systems have reached a point where they provide no defence against otherwise modest insults such as a fall, a urinary tract infection or the flu. Dying in hospital, as I alluded to above, has become the natural order of things in modern Britain (and many other developed health care systems in the world). Also included in this category are the deaths that we would recognise as ‘palliative care’ where even 21st century medicine genuinely has no response – terminal cancer or devastating neurological disease.

Category 2Unavoidable unexpected deaths. These are the genuine tragedies that punctuate life in a hospital. The relatively rare, but affecting cases that litter the landscape of a professional career. These are the maternal deaths from catastrophic amniotic fluid embolus, the brain haemorrhage from an unsuspected cerebral vascular anomaly, the tragically successful suicide or the disastrous major trauma from a road traffic accident (sadly I could go on). These deaths are often met with heroic efforts on the part of hospital staff to prevent them and are followed by dismay and soul searching when unsuccessful. When deconstructed at a later date there is often some learning (we can always do better) but just as often there is little to be learnt – bad things just happen.

Category 3Avoidable unexpected deaths. These are the ones where we got it wrong. Where lapses, incompetence, inexperience, neglect and system failure succeed in lining up in a single case to either actually cause death or prevent avoidable death. These are the cases that stay with you (believe me). This is the missed diagnosis because of a failure to follow up a test result, the failure to act on the deteriorating patient, the unacceptable delay in life saving intervention or the failure to take responsibility for a situation. They are thankfully rare (and overwhelmingly the smallest category of death) – not because the lapses and system failures are rare – they are not – but because (other than in exceptional circumstances) it takes several in a row to have such a devastating outcome, the good old Swiss cheese effect.

I suppose in theory there is a fourth category of avoidable expected death – that feels like a contradiction to me and I can’t conceive what it might be.

The ‘management’ task here is to attempt to assign every death to one of the three categories. That is not a trivial task – and it is not one for which you can take a statistical short cut, however compelling a notion that might be. Not least because in every category there will be deaths where on review there is identified a lapse of care – yet how many lapses does it take to move a death from either of the first two categories to the third?

Lies, Damn Lies and Mortality Statistics

Regular readers of my blog will know that I have been here before in my earlier post: Thinking about Mortality – Fast and Slow. I am not going to rehearse the arguments of the weaknesses of case mix adjusted, risk modified mortality statistics. Suffice to say that the reported ‘dramatic improvement’ in HSMR of the 11 Keogh Review hospitals will have had as much to do with scrutiny of their coding practices as the quality of care they provide.

Professor Nick Black through the PRISM (and soon to be published PRISM 2) study has shown little correlation between quality of care and HSMR (or SHMI or RAMI or any other way of measuring institutional mortality rates). I am trying not to be cynical about these – because they are in fact very useful tools, and cannot be ignored. However one has to be very careful in interpreting them because they tell you as much about what type of hospital you are and what type of patients you treat as they do about the quality of care you provide.

I can tell you without looking that:

Small provincial district general hospitals with proportionately large elderly care, stroke and fractured neck of femur services will have high mortality ratios (however well risk adjusted).

Large urban inner city general hospitals with relatively young transient populations will have low mortality ratios.

Tertiary Centres that carry out high risk care on relatively young patients (like liver transplants or major cancer surgery) will have high mortality ratios.

A Recipe for Managing Mortality

So where does this leave us? We can’t trust the stats and identifying the deaths where we got it wrong, sufficiently to have at least been a causative factor in the death, requires painstaking review of very large numbers of deaths and the judgement of Solomon.

Here are my tips:

1) Don’t ignore the stats – have a committee that looks at your death rates in all specialties and diagnostic groups – identifies the variances, the outliers and the alerts and investigates them even if CQC or Dr Foster don’t notice. You will learn a huge amount about how care is delivered in your hospital and how patients are moved about within it. You will also learn quite a lot about coding.

2) Have a system in place that reviews every death in the hospital. Some have chosen the Medical Examiner solution to this – paying a recently retired doctor to review the notes of every death and extract learning and identify those where more scrutiny is required. We have gone down a variant of the trigger tool methodology – every case is assessed against a set of criteria by a consultant not involved in the care of that patient, if enough triggers are present in one case it gets a table top review.

3) Have a method of sharing the learning – particularly with the consultants doing the screening (in our case that’s all of them), it is laborious work and it has to feel worthwhile. We are not so good at this yet – we have a news letter that goes out, we could and should do more.

4) Don’t trust Dr Foster – they are a commercial organisation that profits from scare stories. Don’t ignore them either.

5) You will find that 70% of patients that fall into category 3 are due to sepsis – invest in physiological track and trigger, sepsis screening tools and implement the sepsis 6 bundle and critical care outreach. Your avoidable mortality will fall.

6) You will also find that acute hospitals provide dreadful care to the majority of patients for whom death is unavoidable and expected (Category 1). The fortunate minority that find themselves under the care of palliative care doctors will get excellent care, the majority that don’t, won’t. Invest in end of life services – this has to be the greatest single priority for the NHS. We are about to publish our ‘Last Year of Life Audit’ – an investigation into the care provided in that critical period of a persons life. It will show that we admit to hospital on average three times in the last six months and start ‘supportive care’ on average 24 hours prior to death.

7) Finally – keep the politicians out, they don’t get it and never will and will do a great deal of harm meddling with stuff they don’t understand. You wouldn’t let them meddle with airport safety would you? why would you let them meddle with hospital mortality…?

We set a new precedent yesterday in one of our A&E’s. Over 400 patients attended and we admitted over 60 patients in one 24 hour period. This is unheard of – a normal ‘take’ in one of our hospitals is 25 – 30 patients from 200 attendances – yet for the last few weeks we have been routinely admitting in excess of 100 patients a day across our two hospitals.

We set another precedent this week as well – we discharged over 200 patients in two days. That is an astonishing number. Of those 200 discharges how many might you think were discharged to the care of social services? The answer is zero – because those two days were over the weekend shortly after the New Year bank holiday. In the same period the number of ‘delayed transfers of care’ has risen to 70 and the number of ‘medically fit for discharge’ (patients no longer requiring medical care but not safe to go home for other reasons) is another 20 or so on top of that. That’s three (unfunded) wards full.

We are under intense pressure – our staff are performing a herculean task – admitting and caring for the sick – shepherding them through the system – and organising safe and efficient discharge – and keeping the floor in A&E safe – just about. That task involves over 60 different professionals for one patient from the triage nurse at the front door through to the community therapies staff that in-reach into the hospital to pull through patients into our intermediate care facilities via the typically three or four different medical teams that might care for one patient during a hospital stay (A&E team, Acute Medical Team, Medical specialty team, MFFD team) – Not forgetting the critical care team that receive the 5% sickest patients on the way.

Yet we are coping. Whilst we have hit ‘Level 4’ at one or other of our hospitals on a few occasions over this period of ‘crisis’ we have never considered ‘closing our doors’ as some others have. And I am convinced I know why.

Synchronous Coordinated Action

Our hospitals march to the drum beat of the two hourly bed meetings. These are brief (less than 15 minutes), always at the same time (8,10,12,14,16,18,20:00 hrs), teleconferences, involving representatives of every part of the pathway from the front of the hospital to beyond the back door, consistent – run to a script, informative – everyone knows what they need to know and leaves knowing what they have to do (discharge 6 patients, 2 before lunch!). A nurse in charge of a community ward will know what the wait times are in A&E. All the time actions are followed up by the operations centre staff – our ‘air traffic control’.

Control of our Outflow

Just over two years ago our Trust took the strategic decision to – ‘move down the value chain’ – we run community services for over half our population and have developed intermediate care facilities in community locations around our catchment area. We are ‘in control’ i.e. have direct access to nearly 100 community beds – including ‘medically fit for discharge wards’ closely co-located but separate from the hospitals and run by GPs.

This has saved our bacon this winter. Its not been plain sailing – it has taken several weeks to get the ‘drum beat’ working consistently and reliably and there have been times when the acuity of admissions have been such that discharges haven’t happened for the ‘right’ reasons and this has threatened to overwhelm us. We have panned the 4 hour target like everyone else – but we’ve done alright for our patients. I am intensely proud of how well our Medical, Nursing, Therapies, Operations and Community staff have pulled together to pull it off.

Its not an A&E Crisis

A&E waits are a symptom of a failing health and social care system. A&E is the only point of care that is consistently available 24 hours a day. Everyone knows where it is, that its always open, that there will always be a doctor there and that you will get free treatment if you need it. People vote with their feet – other parts of the system are either not trusted or simply not available when needed.

The ‘A&E crisis’ is a consequence of un-restrained inflow and significantly constrained outflow. Neither the ‘inflow’ nor the ‘outflow’ is incentivised or held to account for the demands it places on the hospital. It is being in control of at least some of our outflow that helped us weather this particular storm. And therein lies the solution to the problem – if we want hospitals to ‘succeed’ then they must be in control of the resources of ‘outflow’ services and probably ‘inflow’ services as well.

At the moment the philosophy (if organised thinking is a suitable way to describe it) behind the Better Care Fund (The pooling of health and social care resources) is moving in diametrically the wrong direction on this. BCF is moving resources out of health into social care – on the face of it in order to prevent admission to and promote discharge from expensive hospital care. It will not work – however well meaning – it just won’t. Whilst depleted resource in social care is an issue (and a worsening one) fundamentally the issue is one of accountability and control. As long as the services that provide care before and after hospital experience no cost or consequence for sending a patient to or keeping a patient in hospital then they will continue to behave as they always have done. And as these services gradually fail medical takes in hospital of 60 or more will become the norm not the exception.

I have had two curious experiences as a digital citizen this week. It all started with a rather depressing article I read in BMJ last weekend. It was a ‘yes/no’ debate (a common format in the magazine) on the question of whether GPs should allow patients to email them. I found it depressing for two reasons 1) I found it astounding that we should be debating the ‘question’ at all 2) The implication that e-mail might be even a remotely sensible tool for digital access to health care.

Even Digital Doctors Don’t Change

The debate continued on twitter – it appeared to me as a casual observer – that the argument against (apparently the overwhelmingly held view – even of GP twitterers) distilled down to the following:
– GPs are inundated with patients in their surgeries so how could they possibly have time to answer e-mails from them. (The doctor as victim argument)
– Face to Face consultation is a sacred rite of healthcare delivery – any qualitative diminishment of this is a disservice to patients. (The ‘I’ve been trained to do it this way I can’t believe it could possibly be done by a machine’ argument)
– Patients will ask silly or trivial questions and we would be swamped by the worried well. (The ‘We know whats best for patients’ argument) .
– What evidence is there that on-line access reduces demand any way? (The ‘If there isn’t a randomised controlled trial I’m not going to change’ argument)
I was appalled by the narrow perspective, lack of self awareness and how patronising and patriarchal the medical profession still is in 2014. I, rather inadvisably, said so on twitter – and was hit by a ‘twitter storm’ (more of an angry gust if I’m honest) of protest from doctors – what would I know, I’m just an anaesthetist!

Patients Doing it for Themselves

So that was my first experience of an online ‘trolling’ – an important rite of passage as a digital citizen. My second curious experience I’m glad to say was more uplifting. I received an unsolicited invitation from the King’s Fund to take part in a round table discussion about ‘The Art of the Possible’ in a digital future for healthcare. This took place on tuesday night – there were a variety of people – CEOs, MDs, Academics, Community, Mental Health, Industry, DoH (HSCIC) and Patient representatives.

The session started with the absolutley captivating story from Katherine Cormack. She spoke unwaveringly of her experiences of childhood and adolescent mental health problems, the inadequacy of the services provided to treat them and of her attempts to create a solution from the inside (she worked for the NHS for a while trying to set up online help forums for teenagers with mental health issues – but had to give up because of the barriers to change) and eventually joined a social enterprise which has developed an online tool called BuddyApp which creates an online regulated self-help community for patients and therapists.

A long and fascinating conversation ensued – which I can’t divulge because we were operating under ‘Chatham House Rules’. However the messages I took away were the following:

1) There is a desperate desire from users of the health service for it to enter the digital age – they feel ‘locked out’ and rebuffed by an un-listening and un-reformable system.
2) The world is innovating around us – the NHS is being left behind
3) The NHS is a jealous guardian of patients health information and cannot see a way through the mire of data protection, confidentiality and competition law to release it back to them – although in fact there are no reasons why these should be barriers
4) The NHS is incapable of disrupting itself – it cannot release cash from things it is currently doing in order to invest in doing things differently – this was implacably conveyed by the man from HSCIC
5) Yet it is only technology enabled patient self care that has the potential to relive the inexorable rise in demand for NHS services
6) There is a stark asymmetry between the value we (the health service) think we add compared to what patients think we add
7) The NHS has the long history and deep seated culture of a public service organisation that thinks it knows best – this patriarchal culture suffuses the organisation from its civil servants and managers to its frontline clinicians.
8) Those on the inside with insight and the desire to change it are a definite minority – but they are passionate and are seeing and implementing solutions, albeit in small pockets of the service.

Some Myths about Digital Patients

The other strong message that came through is that there are some strongly held beliefs of health professionals about digital healthcare that are simply not born out by the evidence.

Myth 1 – ‘Technology is the preserve of the young and the elderly would be excluded’ – Smartphone market penetration has exceeded 90% in the UK and the fasted growing sector is the over 65s
Myth 2 – ‘The elderly struggle to use or understand modern information technology’ – It is not uncommon now on our wards to see patients young and old using this technology intuitively and effectively. I have seen patients on our elderly care wards ordering their supermarket shopping in preparation for their own discharge.
Myth 3 – ‘Handing out devices to patients will result in them being stolen’ – this is simply untrue – devices have been used in solutions for the homeless and drug addicted with no or minimal loss
Myth 4 – ‘Digital healthcare is a poor substitute for face to face and hands on consultation’ – There is a very large element of health seeking behaviour which is simply looking for trusted advice and reassurance, patients value the continuous access that digital health affords compared to the limited hours and inconvenience of primary care or the appalling experience of A&E.

A Coalition of Radicals

The most uplifting part of the evening was being able to meet and network with developers of solutions for digital healthcare (like BuddyApp), professionals from the health service that have put them to use and representatives from patient groups that have been campaigning for greater patient autonomy and self care through access to their own health record. They are a weary tribe of campaigners because they get little audience from the service they are trying to improve. However there was a clear shared vision and enthusiasm for digital access to healthcare and evidence of real progress from some innovative developers.

It is clear to me that it is this tripartite coalition – patients, third party developers and willing clinicians that will deliver the digital future of health. The only change from inside the health system that is needed is the release of patients own information back to them – and that should cost nothing. Its time to campaign for your right to access your own health information. This innovative disruption will change the NHS from the outside for ever.

We had an ill child in our A&E for over 20 hours yesterday. Read that again – yes its true – 20 hours in an inner-city A&E – on a Friday. Actually she isn’t a child – according to half the professionals that saw her, but was according to the other half. Conveniently for each of them they were able to define her in a way (wrong side of of her seventeenth birthday) that meant neither had to take responsibility for her. A definitive safe place of care was eventually found at an adolescent mental health facility over 100 miles away. Throughout this whole episode she was suffering an acute psychiatric illness.

Fragile Minds

After toddlerhood – adolescence is the most active phase of brain development. It is a critical period during which personality, skills and traits are developed that set the patterns of mind, thought and behaviour for the remainder of adult life. It is a crucial phase of transition from childhood to adulthood – a period of ‘finding ones place in the world’ apart from the security of parents and family. It is an intensely psychologically vulnerable time – one of which we all have memories of our own we would probably rather forget. It is also the commonest period of life for mental health issues to first develop – by some estimates up to 20% of adolescents and young adults are experiencing some degree of mental illness and over 40% of adult mental illness commences in the adolescent period. The combined assaults of alcohol, drugs, sex hormones and dramatic changes in life circumstances on a fast developing brain have unpredictable consequences – which for a growing minority include breakdown, psychosis and the roots of devastating life long mental illness.

When your world falls apart

Psychosis is the most terrifying symptom of disease. It is the awakening of primal fears – normally locked away by evolution and civilisation. Psychosis is the manifestation of every self doubt and vulnerability we harbour, a total loss of security. The very ground you stand on loses its solidity, the certainties of perceived reality evaporate. Paranoia is intense, everyone is against you, every sound becomes the whispering taunting voices – undermining and aggravating self doubt.

During this potentially lethal psychological experience – our service finds it most appropriate to leave the sufferers sitting in A&E cubicles, overseen by security guards and witnessed by the drunken fray that make up the core clientele of A&E on a friday night. Meanwhile professionals play ‘pass the buck’ – skulking guiltily in the background too nervous to engage with a ‘difficult teenager’ – the behaviour surely being noticed and fuelling the paranoid beliefs of the patient ‘for whom no-one cares’.

Why do we do this? Why do we let down such a vulnerable group in such a catastrophic manner?

Too Special to Touch

Throughout my career I have witnessed, and been exasperated by, the phenomenon of medical super-specialisation. This is the process by which small groups of sub-specialists – usually based in well resourced centrally located university hospitals – develop standards of care for a sub-set of a population with a branch of a disease that produce significantly superior outcomes for those patients. This isn’t a problem in itself – this is how the frontiers of medicine move forwards. The problem arises when this standard of care – attainable in the rarefied environment of the academic centre – becomes the expected standard in all healthcare settings. A process of centralisation of care then ensues – as ‘good enough’ becomes the victim of ‘perfection’ – standard care in general settings is discredited. Generalists are stripped of the right to provide certain aspects of care – patients are diverted to diminishing numbers of ever distant specialist centres – as the skills for providing even ‘good enough’ care at local centres evaporate.

One of the most striking areas of medicine where this has happened is children’s services. Most paediatric services are now provided by centrally located children’s hospitals – these highly specialist tertiary centres do a fantastic job – but to survive they have had to grow their business ‘down the value chain’ to the point where they now also provide the bulk of standard secondary care. This has resulted in the shrinking of paediatric services in district general hospitals to below critical mass levels – many paediatric services have closed – many others are teetering on the edge of viability, even in quite large general hospitals. It is reaching a point where in many hospitals it is just unsafe to be a child – and the doors are simply closing on them.

This march of progress wouldn’t be a problem if wasn’t for the fact that very sick children – whether physical or, as in our story above, mental – still come to A&E expecting life saving treatment. Our doctors, with dis-credited general skills, diminished exposure and experience – are not only discouraged but actively criticised for trying to provide good enough care. So they have stopped – and patients languish in A&E awaiting transfer to over subscribed specialist centres – not receiving immediate care they need that might prevent harder to treat long term conditions. Meanwhile the generalist tiptoes around them – too terrified to touch.

A Relentless Epidemic

Childhood and adolescent mental health is very special indeed. Most ordinary doctors are scared of mental illness – this is hived off very early in training – and even more scared of children. Yet the story of our seventeen year old in crisis is becoming more not less common, what was a handful a year presenting to our A&E has become dozens a month. We don’t know why – but the wide availability of cheap alcohol, potent cannabis, met-amphetamines, and other ‘legal’ highs along with the as yet un-evaluated impact of the psycho-social complexity of a life lived ‘on-line’ must all be playing a part. And this is a drama that is being played out in emergency departments across the NHS – daily.

There is an urgent need to find a solution for delivering safe ‘good enough’ care for these patients – at the point of presentation – until a place of definitive care can be found. The needs are not complex – but they do transcend organisational boundaries – the ability to provide safe dependable holding treatment in an urgent mental health situation – is a good test of health system integration. The care of the intoxicated, potentially physical injured patient that is in the throes of a mental health crisis requires professionals that normally work in isolation (traditionally somewhat distrustful of each other) to come together and meet the physical and psychological needs of these patients.

Above all this needs system leaders to come together, organise their services to deliver and demonstrate that – yes, we do care about this calamity – we care very much.

Over the next 2 years many NHS Hospitals will be replacing electronic health record (EHR) systems as the contracts born out of the national program for IT (NPfIT) come to an end. They are doing so amid a noisy revolution in healthcare informatics – which is demanding that we completely reframe not just our ideas about the EPR itself but also the nature of healthcare delivery and the traditional medical model.

I have previously talked about the cumbersome desk bound IT systems that have been as much an impediment to the process of care as a source of misery for the users of these systems. Why is there such a mismatch in expectations of healthcare staff and the developers of the tools supposedly there to help them? I don’t believe we can blame the developers of the systems – or for that matter the users of them. I believe that it has come about because we have all failed to understand the true nature of modern medicine and it has taken the social media revolution to wake us up to the fact.

Transactional Healthcare

All our current systems – IT, contracting, measuring, counting and operational delivery – are designed around the notion that healthcare is a series of individual transactions, each transaction taking place under the auspices of an individual clinician (e.g. the finished consultant episode – FCE). The overriding assumption of this model is that healthcare is episodic, that between episodes we have no contact and no need for contact with the healthcare system and that each episode is presided over by a clinician that has, if not control, then at least knowledge of what is happening. It also assumes that of the information required to manage an episode of care only a proportion of it is of relevance to future episodes – and that episodes of care have largely self contained information needs.

Notwithstanding this, what a typical patient might consider a single episode of healthcare actually consists of large numbers of individual transactions often with several different organisations and several different parts of the same organisation (GP, Outpatient department, Radiology, Pathology etc.). The ‘system’ has fragmented itself – for its own purposes – and has at the same time failed to provide a reliable mechanism for the sufficient sharing of information between its different parts to give any sense of continuity – let alone impression of competence – to the hapless patient.

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The NHS far from being a single organisation is an aggregation of large and small institutions, thrown together in a pseudo-market notionally in competition with each other – with strict rules that prevent them from collaborating (competition law) and sharing information (data protection). It is designed to fail to meet the continuity challenge and the expectations of patients. It is also unsafe – with manifold opportunities for vital information communication failure, a common root cause of critical incidents and serious complaints.

This transactional model has developed out of the medical model that assumes patients have singular diagnosable diseases that are amenable to technological intervention (pharmaceutical or surgical) and that life long cure is the outcome. This is certainly the case in a proportion of healthcare interactions – but medicine and patients are changing. The vast majority (in excess of 70%) of healthcare delivery is for the multiply co-morbid patient with conditions that they will live with for the rest of their lives. There may indeed be episodic deteriorations in their condition, that result in (expensive) episodes of highly technological healthcare – these are however often both predictable and avoidable manifestations of a long term condition for which there is a continuous healthcare need.

Social Healthcare

A new medical model – that fits the needs of 21st century patients – is emerging in the era of social networking. Social Healthcare – this model assumes that the patient has a continuous need for health intervention and that this is delivered by a network of providers that the patient invites in to their ‘health space’. A long term condition demands a multitude of interactions over a sustained period of time with many providers. Our current system fails to ensure that those providers interact with each other over the same patient using the same information as it cannot guarantee that they ever have access to the same information (or even know that they are looking after the same patient). In the social healthcare model the patient is the guardian of all information about themselves. Their information sits in ‘the cloud’ but they hold the key to its access. Over time they build a personalised health care team who have access to their cloud data and can ‘talk’ to each other about the patient through his or her ‘health space’. The patient can source information about their condition, ask advice or consult through the portal to their health space at any time of day or night. The portal allows for direct consultation through a skype like interface. Even more powerfully the patient can consult with other patients who have the same conditions. A self supporting community emerges that can provide advice, support and shared experience – on a continuous basis. “It’s like having a waiting room conversation with 1000 other people – just like me”.

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This new model has the potential to have a powerful enabling impact on patients. It subverts the traditional hierarchy in the health transaction, puts all providers on an equal footing below that of the patient – who becomes the master of their own information. Networks of expert patients start to generate new kinds of knowledge about the nature of disease and the impact of interventions – crowd sourced evidence creating medicine. Patients have the power to choose who contributes to their health space – based on the value they add to them as individuals.

Preparing to be part of the Crowd contributing to the Cloud

What does this mean for providers of health care that are in the process of renewing their informatics systems? What does this mean for me as an individual doctor? The truth is the system described above doesn’t yet exist – there is nothing yet that will force me as a doctor to change my clinical practice in such a way as to make myself available through the cloud to individual or groups of patients on a continuous basis. There is nothing yet that will force the hospital that I work for to make available all the information it holds about patients to patients through a cloud portal – or share that information with other providers of that patient’s choosing. Nothing yet – but it is coming…

Third party providers of patient centred health portals are are emerging – from a variety of premises and care models – but are converging on something that looks similar to the ‘social healthcare’ system. Patients like me, Patients Know Best, Health Fabric and Skype Health are all examples of emerging technologies that will deliver the vision. And they are selling their wares not to doctors, healthcare institutions or commissioners – they are selling them to patients.

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What this means then is that the systems we purchase or develop will need to have the ability to talk to these providers, transfer information, support voice and video links. We will have to think through how the information outcomes of healthcare transactions will be recorded in a way that can meaningfully sit in a patient’s cloud – shareable with other providers and understandable by patients.

What this means for doctors is a shift from practicing intermittent transactional healthcare – to developing a personal online continuous relationship with our patients and being part of and interacting with the crowd of providers that are also caring for them.

Welcome to the future of medicine – are you ready?

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For as long as there has been healthcare we have struggled with developing economic models for its delivery. The variety of models that exist across the world – from the raw market seen in many developing countries; through various degrees of private / state sponsored insurance; to the pure state funded provision we enjoy in the NHS – attest to the fact that there is no ‘right answer’ to this conundrum.

The Funding Paradox of Healthcare

Most healthcare systems in one way or another attempt to resolve the inevitable paradox that in the majority of cases those in most need of healthcare are also the least likely to be able to pay for it. As a result most systems are a manifestation of a ‘collective bond’ between society and the individual – ‘We’ will pay for your healthcare when you need it as long as ‘you’ contribute what you can when you don’t.

Different systems manifest the bond in different way – Through direct taxation, private or state subsidised insurance. Even the least developed systems, that rely on direct payments for care have a degree of economic re-distribution built into them, with wealthier clients overpaying to subsidise the poor and charitable donations making up the difference.

Does the funding mechanism affect the amount of money the ‘collective’ is prepared to spend on healthcare? Interestingly it appears not to be the case – the biggest determinant on how much is spent is the wealth of nation, but the relationship is geometric one i.e. the wealthier a nation the greater the proportion of GDP is spent on healthcare. The graph looks like this:

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Justice and Equity

Where systems do differ significantly is ‘in what way’ and ‘on whom’ the money is spent. The lesson from international healthcare system comparisons is that, in general, the greater the involvement of the state the better are the measures of ‘Universality’ i.e. distributive justice and equality of access.

Universality is not the only outcome we want to achieve from our healthcare funding system though – there is no point in having universal access to a system that is no good. Universality is ultimately, like funding model, a policy decision. It is a decision by the collective on how it would like to distribute the healthcare funds it has decided it can afford – both are the product of culture, politics, history and national character. But neither universality nor funding model alone determine health outcomes. Changing either of these is unlikely to improve the quality of care or the cost of its provision.

Is the NHS Any Good?

So, the NHS is funded to the level we would expect for the size and wealth of the nation – it scores pretty well (one of the best) on universality, although we lose points because we do tend to ration care by putting people into queues (but that is part of our national character). How do we know if we are getting the healthcare we are paying for? How do we know if the NHS is Good Value? To answer this question we have to understand the notion of value in healthcare.

Value is a fundamental function of any free market economy – it is an equation all of us reconcile, either consciously or unconsciously, every time we part with money for goods or services. We all make a calculation as to whether a particular good or service is ‘worth’ the amount of money we are about to part with. The solution to the value equation is always a very personal one – it varies enormously between individuals and even within the same individual at different times and in different contexts (most of us are prepared to pay more for a glass of wine to accompany a meal in a restaurant than we are for one when watching TV at home). Value drives market economics – it drives quality up and costs down – it improves quality of life and increases wealth – it is the triumph of market capitalism. But – it only works as long as the reconciliation of value (Worth/Cost) takes place within the same individual or entity. You cannot reconcile value if you are spending someone else’s money.

Let me tell a story to illustrate the point…

A Bitter-Sweet Motoring Tale

Just over two years ago I finally got around to replacing our family car after 8 years of neglecting the task. Having not thought about it in all that time I was for a period gripped by a frenzied interest in the family car market. After browsing the internet, buying the magazines, and even stepping into a car show room for the odd test drive – I ultimately had to come to a decision between 3 car types (having already decided that I wanted a medium sized family estate). These types are essentially ‘Low-End’ (cheap and cheerful e.g. Citroen, Seat, Fiat), ‘Mid-Range’ (Popular Reliable e.g. Ford, VW, Skoda) and ‘High-End’ (Designer, Classy, Expensive e.g. BMW, Audi, Lexus). In terms of cost low-end were in the range £12K – £15K, mid-range approximately £5K more than that and high-end another £10K on top of that and in excess of twice the cost of low-end. Having previously experienced the catastrophic residual value loss associated with the low-end of the market and been persuaded (conscience and wife in equal measure) that I couldn’t afford to go down the high-end route I settled (like many do) for a mid-range model and became the proud owner of a Skoda Octavia Estate. My personal ‘value journey’ has resulted in a car I am delighted with at no more cost than I was prepared to spend, and I am pleased to say the residual seems to be holding up nicely! My delight has only been tempered by the extraordinary hike in the cost of insuring it compared to the old car…

I was, unfortunately, involved in a car accident not so long ago – no one injured thankfully – but the car was off the road for several weeks. My positive motoring experience continued though – the insurance company appeared eager to help me out, arranging immediate retrieval of the vehicle, replacement with a hire car personally delivered to my front door, insistence that I put forward any personal injury claim (there was none). My car was returned to me weeks later in an immaculate condition having undergone repairs approaching half the cost of the original purchase price. The whole ‘accident experience’ was really no inconvenience to me at all, and I am told that the quality of repairs these days means that it will have no impact on residual value either. All great – but at what cost?

The car insurance market in recent years has undergone phenomenal price inflation – at times exceeding background inflation by a factor of ten. The introduction of ‘claims management companies’ ‘Personal injuries claim farmers’ ‘Professional body shop repairers’ ‘Replacement car hire’ etc. – have inflated the cost of motoring accidents massively. Everyone involved in the car accident ‘value chain’ appears to to be exceptionally eager to please and also appear to be profiting handsomely – in fact the whole trade was recently investigated by the OFT for profiteering. How has this runaway inflation been allowed to happen? It is a consequence of the fact that the value equation has become ‘de-coupled’ – whilst benefit is experienced by the individual the cost is shared out amongst the pool of the insured. I have contributed a small amount to overall inflation in the cost of insuring cars against accidents – had I been paying directly for the consequences of my accident would I have chosen such a high cost route to resolution? The fact is the system is locked into an inevitable inflationary spiral as no-one is controlling costs.

The market in new cars is a healthy market – it has delivered incredible improvements in the quality of cars over many years and at the same time kept costs down – the value equation is always resolved by the purchaser. The car insurance market is broken – delivering runaway inflation and ever diminishing value.

Delivering Value in Health

I am sure you will have realised that I believe that healthcare ‘markets’ share more in common with car insurance than they do with car manufacturing. That is why marketisation of healthcare has failed to deliver value.

The value equation in healthcare is on the face of it simple but is nuanced and complex – it looks like this:

VALUE = (Quality + Outcome) / True Cost of Delivery

The equation is reconciled rather uneasily within the ‘triumvirate’ of Patient, Provider and Payer. The providers are profiting (in this context by profiting I mean existing) from being fragmented, with no incentive to prevent costs being passed along the ‘value chain’, and plenty of incentive to do more at more cost to the payers. The patient experiences the quality and the outcome (often at some significant distance in time from the transaction) but has no notion of the cost. The payers are faced with irreconcilable demands for increasing scope and quality, limited levers of control of costs and under-developed measures of quality and outcome. All of this fuelled by the easy altruism of the providers spending someone else’s money.

Marketising Integrated Care

How can we yield the incredible power of a well functioning market to deliver increasing quality at reducing cost but not at the same time create a runaway self inflating market? Where in the system can we bring together the quality and outcome (as experienced by the patient) with the true cost of delivery (as experienced by the payer) in order to create value?

The answer, ironically enough, is coming from the US healthcare system. This has experienced the kind of runaway inflation described above and led it to becoming the most expensive healthcare system that has ever existed delivering aggregated health outcomes little better than systems costing less than a quarter per head of population. Yet the payers (in this case private insurers) have spotted the flaws in the market – the fundamentally self inflating structures of healthcare that incentivise primary care to refer, secondary care to receive and over diagnose problems for which they profit from treating. Their solution has been for the payers to move into the provider space – creating integrated healthcare systems. In doing so they have incentivised ‘doing less earlier for a better outcome’ – incentivised prevention, incentivised early accurate diagnosis, incentivised the creation of ‘activated patients’ and incentivised best value treatment. ‘Payer-Provider’ healthcare systems in the US such as Kaiser Permanente, Veterans Affairs and others are profiting from integrated care. They are deconstructing traditional silos and re-building delivery systems organised around whole value-chains – delivering end-to-end care for dramatically less cost. The market is moving from a market of healthcare providers to a market in integrated care organisations – providing whole life cycle care.

Time for a New NHS?

We want a better value NHS – one that delivers more and higher quality care for the same or less cost. This is a reasonable objective. We won’t achieve it by meddling with funding model or universality – these are predetermined and would require a re-negotiation of the collective bond, and would not deliver better value. We won’t achieve it by fragmenting the provider market – that will create a runaway self inflating system of passing the cost up the value chain. We might achieve it by integrating providers around whole cycles of care. We have been talking about integration in various guises for years but have delivered little as we remain in a purchaser provider split and a primary secondary split all locked in self preserving stalemate. What has been missing is the incentive to integrate and that comes from integrating payers and providers. This is for the NHS the slightly awkward lesson coming to us from over the Atlantic.

As a medical director I am routinely required to assess, grade and act on the results of serious adverse events that have occurred in hospital. Often these events have resulted from failures of care through lapses, oversights, errors or neglect. This is often accompanied by a clarion call for some form of disciplinary action and or restitution – usually most insistently from within the organisation rather than by those directly affected, either carers or the patients themselves.

Bad things happen in hospital all the time. Healthcare is the only industry where for a significant minority of users the outcome is death or injury, either expected or unexpected. The overwhelming priority in this situation for both the recipients and providers of the care is learning: learning the truth of events, learning if it was avoidable, learning how it might be avoided in the future, and sharing that learning so it might be avoided elsewhere.

Prerequisites for Organisational Learning

We have, as human beings, an innate gift for learning – it is built into our DNA and, whilst most active in our early years of life, never really leaves us. Individual learning is the most powerful lever of change in human societies, because people love to learn and change as a result. Teams and organisations are made up of people and yet team and organisational learning does not happen by chance as it does for individuals – team learning is an unnatural and deliberate act.

There are three prerequisites needed within organisations in order to promote learning from error and system failure. It is strangely rare to find them all reliably present in healthcare organisations.

  • A Learning Environment
  • A Team Based Learning Infrastructure
  • A Compelling Vision Delivered Through Leadership
  • I will expand on these three prerequisites, but first I want to explore why they are found rarely in our hospitals and healthcare organisations.

    Two Key Barriers to Organisational Learning in Hospitals

    Hospitals are busy places, this is a universal truth – not unique to the NHS. The work processes of nurses and doctors in hospitals rarely run smoothly – they are by their nature characterised by frequent interruptions, unexpected deviations and minor crises. In order to get the job done a large part of the work involves having to create on-the-hoof workarounds and solutions to problems – giving rise to the familiar sense of almost continuous ‘fire fighting’.
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    We are actually incredibly successful at doing this, much of our individual innate learning capacity is consumed developing coping strategies for the chaotic environment we find ourselves in. The problem with this ‘first order problem solving’ for ‘low level failure’ is that the learning it generates is of value only to the individual nurse or doctor – they are simply adapting to the flawed environment they find themselves in – just to get the job done. In doing so they are condemning themselves and and their successors to having to learn the same lessons in perpetuity – this grinds you down and drives talent away from ‘the front line’. How do we break the cycle of low level failure that requires constant first order problem solving making every day work flow inefficient and time consuming? The first step is to recognise the problem and then acknowledge that low level failure, whilst common place, is neither inevitable nor acceptable. The next step is to then deliberately and collectively make the time to move first order problem solving into second order problem solving (of which more later).

    The second key barrier to organisational learning in hospitals is a deeper, more cultural one. This is to do with interpersonal attitudes and responses to error. The shameful truth is that the overwhelmingly pervasive culture is a blaming one that inhibits speaking up with questions, concerns and challenges that might otherwise have caught and corrected human error. Moreover there is a culture in medicine that does not encourage admissions of error. Both ourselves and others have high expectations of success in medicine – when we don’t meet those expectations we are as blaming of ourselves as we might expect others to be. What is interesting is that the direction of blame isn’t just top down – in fact top down blame only really materialises when the failures mount up to catastrophic levels. The vast majority of, and undoubtedly more corrosive, blame is that of our colleagues and peers. What is clear is that whilst blame remains the primary response to failure opportunities for learning will be lost and the quality of the lessons learnt will be poor. Overcoming this barrier is a true challenge of leadership at all levels of an organisation as it requires a change in culture – a clear and sustained statement and restatement of values, unwavering adherence to behaviours that follow from those values, even in the face of challenges from within and without the organisation.

    Leading Learning for Patient Safety

    So where should we start with creating a learning culture in our organisations? The answer has to be with leadership, because without leadership on this issue nothing else can follow. The type of leadership and skills required to lead learning, however, are not what are typically viewed as traditional leadership skills. The leadership model for leading learning differs from the traditional leadership model in several important ways:

  • Whilst a ‘burning platform’ undoubtedly exists, the future state can only be guessed at (in an educated way)
  • This makes it hard to articulate
  • The flaws in the current state are hard to spot – there is a deep seated culture of acceptance of low level failure
  • The way forward is not a clear plan with deadlines and critical paths but a process of experimentation, a gradual reduction of uncertainty and regular revision of interim goals and ultimate vision
  • The leadership task is primarily one of engagement and reduction of fear not a promotion of employee effort
  • The task will never be finished
  • If you have read my previous blogs you might guess that I believe these ‘New Model Leaders’ need to come from the rank and file of doctors, nurses and other healthcare professionals that don’t often put themselves forward for such a role.

    Second Order Problem Solving and A Team Based Learning Infrastructure

    Second order problem solving is about creating long term fixes for recurrent problems, it is about analysing root causes and putting in place solutions with ‘traction’, it is often about changing behaviours in ourselves that have consequences for others. There are several reasons why we don’t stop and take the time and effort required to convert first order to second order problem solving. First of all – it does take both time and effort – neither of which we have much left of after a day / week / month / years of fire fighting. Secondly the problems we need to solve are quite often not even perceived as problems, we have been compensating for so long it has just become part of the job – this is where our new model leader has to be insightful. Thirdly second order problem solving requires some quite specific skills such as root cause analysis, process mapping, and change modelling that are not commonly found in healthcare teams. Fourthly – we are quite proud of our first order problem solving, being a coper and thriver in a stressful front line job is associated with significant kudos, particularly in the hospital environment. Finally it does require us to meet as teams for a significant time on a regular basis – which we are astonishingly bad at doing – and when we do for those team meetings to be led in a way that promotes speaking up, learning from others, admissions of failure and a willingness to innovate (and therefore risk failure). This final requirement leads on to the the final pre-requisite for organisational learning – an environment of psychological safety – A Learning Environment

    Blame Free Culture Vs Accountability – A Balance that Creates ‘Psychological Safety’

    Our new model leaders have their work cut out – not only do they have to create time (in an already overloaded time table) to bring together teams (who are singularly reluctant to gather) to discuss both low level and high level failure (failures that may not even be recognised as such) and defend these notions against pressures to use the time ‘more productively’; but also resist the temptation and pressures from above, inside and out to apportion blame for every failure that comes to light. The prize is great if they achieve it – a learning environment in an organisation that continually improves both itself and the people that move through it, one that delivers both on the economic and quality front. A true value adding organisation.

    But – it can’t all be so idyllic surely? People do also make mistakes borne out of stupidity, brazen over confidence, ignorance, stubbornness, laziness, jealousy and – yes – even malice. There is a level of human behaviour for which we all need to be held account. There is also a performance imperative, we all have to be helped to raise our game. Where is the place for accountability in a blame free culture? The diagram below will perhaps help you decide…

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    This is the essential difference between ‘blame free’ and ‘psychologically safe’ for the latter comes not just from creating an environment where people feel able to speak up and admit failure but also feel assured that when boundaries are truly crossed that individuals will be held to account. This is the real test of leadership – knowing and communicating expectations and boundaries as well.

    Blameworthy Acts – the Boundaries of a Blame Free Culture

    Where do you draw the boundaries? There are no text books, there are no rules – there is intuition and there are inspirational leaders we can follow. Here is my starter for ten of blameworthy acts:

  • Reckless behaviour
  • Disruptive behaviour
  • Working significantly outside your capability
  • Disrespectful behaviour
  • Knowingly violating standards
  • Failure to learn over time
  • Failure to work as a team
  • Covering up
  • No doubt there are more. Clear boundaries around a learning zone create an environment in which organisations can thrive and patients can feel and be safe.

    I have to acknowledge the source of the ideas for this article. Amy C Edmonson – a truly inspirational teacher at HBS who not only articulates this message with conviction but backs it up with the irrefutable results of research both in healthcare and other settings.

    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.