ECH Campus: Dr Martin Connor

Transforming systems

Connected Health Campus Keynote

Dr Martin Connor

Deputy CEO

Trafford PCT

May 7 2009

Sound familiar?

“[There was]…a panoply of ‘special commissioners’, backed by their own bureaucratic apparatus, for different facets of the four year plan, often without clear lines of control, not infrequently overlapping or interfering… It was a recipe for administrative and economic anarchy”

Ian Kershaw, ‘Hitler’ p. 367

The strategy needs not to be about marginal adjustment but about system transformation

1) Who am I?2) Two case studies3) Some key concepts4) A novel idea (perhaps)5) A work in progress6) Outcomes of case studies7) Conclusion

Contents

CASE STUDY ONE:

A collapsed healthcare system

In September 2002:

• 146,800 patients were waiting for a first outpatient assessment

• 54,600 patients were waiting 6+ months

• 16,100 were waiting more than 18 months

• Some patients waiting up to 10 years

Case Study One: Northern Ireland Access - Outpatients

In September 2002:

• 60,200 patients were waiting for inpatient or daycase treatment

• 28,300 patients were waiting 6+ months

• 9,200 were waiting more than 18 months

Case Study One: Northern Ireland Access - Surgery

Individual specialties – maximum treatment waiting times

Specialty Sept 2002

Cardiac surgery 5 years

Ophthalmology 5 years

Orthopaedics 7 years

Case Study One: Northern Ireland Access

Surgery waiting 2002 - 2007IP/DC Waiters - All Specialties

0

5000

10000

15000

20000

25000

30000

Jun-02 Sep-02 Dec-02 Mar-03 Jun-03 Sep-03 Dec-03 Mar-04 Jun-04 Sep-04 Dec-04 Mar-05 Jun-05 Sep-05 Dec-05 Mar-06 Jun-06 Sep-06 Dec-06 Mar-07

Over 6 months

Over 12 months

Outpatient waiting 2002 - 2007

OP Waiters - All Specialties

0

10000

20000

30000

40000

50000

60000

70000

80000

90000


Over 6 months

Over 12 months

CASE STUDY TWO:

A failing inner city comprehensive school

Results

Spare capacity

Directed entrantsTraditional recruitment

Behaviour standards

‘Sink school’ cycle of low attainment

We start here with a history of poor results

and behaviour problems.

This impacts on our recruitment from our

feeder schools, giving small Year 7 groups…

…which results in a lot of spare capacity.

This means very high numbers of non-

traditional entrants destabilise the school

In the absence of an effective behaviour

management strategy, this causes a major

deterioration in standards

In this cycle, results will

always be poor

Which leads to poor results

Headline results over 7 years

0

5

10

15

20

25

30

35

40

2000 2001 2002 2003 2004 2005 2006

Results year

% 5

A*

- C

% 5 A*-C

Aaagh, that’s my kids in there…

Falling numbers

0

20

40

60

80

100

120

140

160

180

Year 11 Year 10 Year 9 Year 8 Year 7

No

ch

ild

ren

Girls

Boys

This was the financial timebomb…

KEY CONCEPTS

KEY CONCEPT ONE: DROP THE PILOT

It’s not about pilots because:

They suffer from the problem of scope

‘Transferable solutions’ don’t transfer

Solutions at scale are different in kind to successful projects –

Because of risk (and therefore permissions)

Because of management resources

Because something will happen that will touch everyone – this is scary

KEY CONCEPT TWO: WHOLE SYSTEM CHANGE MEANS A WHOLE DIFFERENT APPROACH

If it’s not about pilots, then what is it about?

It’s about the top of the shop (first… to make the strategic offer authentic)It’s about the patients (nothing about me without me – populations too?)It’s about the data and information (frequency, quality, timelag)It’s about the doctors (for permission and insight… and when the going gets tough)It’s about the nurses and AHPs (the vanguard of the revolution)It’s about the general management (for project management, resources and assurance)It’s about the institutions (existing… and new?)And…It’s about the vision thing…

The difference between a vision and an aspiration:

Whilst they are both about notions of a better future…

An aspiration is a vague description without sufficient clarity to enable a connection between the desired future state and the next immediate action

A vision is a vague description (and necessarily ambiguous to enable ownership) that is sufficiently clear to ‘reach back’ into the present and act as a guide to the range of next steps that could be taken to move towards the goal

KEY CONCEPT THREE: IT’S AN UNCERTAIN WORLD

There are (I argue) five distinct species of uncertainty:

Ambiguity (the source of most conflict, and the death of effective strategy)

Vagueness (the reason for most failure from design to execution)

Indeterminacy (the risk of freedom)

Agent (what might the other fellow do?)

Future (time goes by at one unique second per second)

A NOVEL IDEA

THE PHILOSOPHY OF LEADERSHIP

Story telling

Virtues Quantification

PersonalCommunity

Cosmic

Gentleness

Humility

Compassion

(Unambiguous)Definitions Diagnosis

Monitoring

Three pillars

So what’s exciting NOW!

(I feel hungrily ignorant – bring it on!)

THE TRAFFORD GAMBIT(Could we leapfrog Kaiser in the NHS through

structural reform?)

Beds &Theatres

Outpatients

Primary care

Community

Nested CapacityWe should explore the introduction of office medicine to replace the primary care/ outpatients distinction…

… and secure appropriate differentiation of specialist surgery to introduce world-class models of care…

… whilst bringing together the various strands of acute medicine, A&E, urgent care, out of hours and intermediate care to deliver a more effective unscheduled care system.

Inaugural Trafford Clinical Congress

Process and proceedings

23rd/ 24th September 2008

“Exploring integrated services”

13 How do we go forward?

There was unanimous support for the principle of integrated service provision from the clinicians that attended the Congress.

During the final session, the general management community was mandated to bring forward proposals for how this might be organised. This paper lays out these proposals at their preliminary stage of development.

21 Feedback (VIII)

Quantitative Questions

1 2 3 4 5 6 7 8 9 10

Strongly Disagree

Disagree Not Sure

Agree Strongly Agree

1 2 3 4 5 6 7 8 9 10

Strongly Disagree

Disagree Not Sure


1 2 3 4 5 6 7 8 9 10

Strongly Disagree

Disagree Not Sure


1. There were opportunities for the group as whole to find its own direction?

2. The group as a whole used the opportunities given to it, to shape the direction?

3. The congress enabled the group as a whole to learn and talk about their own processes and interdependences

Min - quartiles- max

22 Feedback (IX)

Quantitative Questions

1 2 3 4 5 6 7 8 9 10

Strongly Disagree

Disagree Not Sure


4. From a group perspective there was a willingness to build a negotiated view of how to proceed in terms of integrated services for Trafford

5. Please circle where you think we are currently as an integrated organisation

6. Please circle where you think we can be as an integrated organisation in 18/12 time

Siloed /

Isolated

Divided no more

Finding kindred spirits

Going Public

Developing Standards

and practices

New Mainstream

3 20 14 2

Siloed /

Isolated

Divided no more

Finding kindred spirits

Going Public

Developing Standards

and practices

New Mainstream

1 9 1 1216

Min - quartiles- max

Fragmented Integrated

Taken from Parker Palmer - Movement Model of Change

Taken from Parker Palmer - Movement Model of Change

RESTRUCTURING A HEALTHCARE ECONOMY

Present high-level commissioning

Acute provision

GP1

GP4GP2

GP3 GPn

PCT

Community services

Non-PbR services

Outpatients and

diagnostics

Inpatient, daycase, specialist

… and we have persistent issues of poor integration, resilience and perhaps quality… is there a structural problem?

(Independent)

Acute provisionPCT

Community services

Non-PbR services

Outpatients and

diagnostics

Inpatient, daycase, specialist

GP1

GP4GP2

GP3 GPn

(Independent)

And social services..?

Consultants, GPs and nurses/ AHPs as partners?

Integrated Care Record

Future high-level commissioning?

Tackling the democratic deficit/ enhancing local control

PUBLIC ENTERPRISE COMPANY/ COMMUNITY FT…?

…MADE UP OF ‘MEMBERS’ ON GP LISTS…?

Community services

Non-PbR services Outpatients

and diagnostics

GP1

GP4GP2

GP3 GPn

(Independent)

Consultants, GPs and nurses/ AHPs as partners?

Integrated Care Record

Exploiting the GP registered list

GP Information Sharing Hub - Logical Overview 2

Practice Systems

Confidentiality

agreement

Patient Level

AnonymisedData

Confidentiality

agreement

InformationHub

Confidentiality

agreement

GPPractice

PCT

Existing Interface

EMIS

INPS

Isoft

(Other)Commissioning

Processes

Ownership

Out Of Hours

Out of hours View

Enhanced Clinical Programmed

Public Health Outreach

GP Governance Board

Confidentiality

agreementExisting Systems

Data Viewing

Agreement

Data Quality

Data Quality

Data Usage

Agreement

Data Quality

Requirement

Ownership

Data quality M

anagement

FOUNDATION

LEVEL TWO

LEVEL THREE

LEVEL FOUR

General medicine, family medicine, continuous care

Definitive differential diagnosis, specialised condition support

Invasive work and exacerbation support

Surgery

Diagnostics

Medicine

Specialised services

General Practice

General practice, provider services, OP, diagnostics

FT/ NHST/ IS

Regional and sub-regional

centres

Regional and sub-regional

centres

General Practice

ICO

ICO + any willing provider

GMS/ PMS

Post-PbR

PbR/ Post-PbR

Specialised commissioning agreements

HEALTHCARE COMMISSIONING PROSPECTUS

Designation Function Present Future Funding

Delivery

PACE OF CHANGE

GOVERNANCE PACE OF CHANGE

2009/ 2010 2010/ 2011 2011/ 2012

Memorandum of Understanding

(Heads of agreement)

Formal joint venture

(new financial flows)

New institutional framework

Independent development partner?

CASE STUDY ONE:

Results

Surgery waiting 2002 - 2007IP/DC Waiters - All Specialties

0

5000

10000

15000

20000

25000

30000


Over 6 months

Over 12 months

Outpatient waiting 2002 - 2007

OP Waiters - All Specialties

0

10000

20000

30000

40000

50000

60000

70000

80000

90000


Over 6 months

Over 12 months

CASE STUDY TWO:

Results

Key Stage 4 results trend

0

10

20

30

40

50

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

5+A*-C 5+A*-C Including English and Maths

KS4: Best Results for at least 14 Years


Despite


Despite

Being the least able year group on entry


Despite


Having a massive level of mobility and disruption over 5 years


Despite


Having a massive level of mobility and disruption over 5 years

Only 20% being on target in September 07

%A*-Cs vs FFT D estimates

20

25

30

35

40

45

2006 2007 2008

5A*-C FFT D Est

Loreto % 5A*-CResults better than top 25% of

similar schools

KS4 Loreto Trajectory from Targets

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

2007 National 2006 Actuals 2008 Actuals 2009 School Targets

5A-C

5A-C incl E&M

2 levels En

2 levels Ma

2007 Nationals

Minimum KS4 Trajectory 2009

National benchmark

KS4 Loreto Trajectory from Targets

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

2007 National 2006 Actuals 2008 Actuals 2009 School Targets

5A-C

5A-C incl E&M

2 levels En

2 levels Ma

2007 Nationals

Minimum KS4 Trajectory 2009

Match national standard with least able year group

National benchmark

Increase in preferences towards viability: An indicator of community confidence

0

50

100

150

200

250

300

2004/5 2005/6 2006/7 2007/8 2008/9 2009/10

All parental preferences

Number of places allocated: Pupil numbers moving to viability

0

20

40

60

80

100

120

140

160

2002/3 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10

Number of Places

New school plan initiated here

Projected Pupil Numbers 2009 - 12

0

100

200

300

400

500

600

700

800

2009 2010 2011 2012

Pupil No's

One set of problems solved…

Conclusion

Things can – they really can – be much, much better – but let’s think in 10s of %, not marginal improvements

Transformation requires thoughtfulness, patience, a touch of Machiavellianism – and the application of systems logic

In healthcare, I believe one of the new challenges is to build new institutions that are professionally led and individually responsive

And finally…

Ultimately, it’s not about the system…

“Men try to escape the darknessWithout and withinBy dreaming of systems so perfectThat nobody needs to be good”

- T. S. Eliot

Choruses from ‘The Rock’ VI

I believe we should consciously resist this temptation and instead use technology to better support human judgment within professional relationships. Ultimately – quality scares notwithstanding – we need to carry on trusting each other.

Health & Medicine

ECH Campus: Dr Martin Connor