I am not asking for the moon…….

Back in the early part of the noughties, I was a senior civil servant. We had a big debate about where we should focus policy after putting huge increases in staff and funding into the NHS. The answer? “Quality”. We have been improving quality, in broad terms,  since – through National Service Frameworks, Cancer Improving Outcomes Guidance, higher satisfaction….

Yet we still have catastrophic failures in some organisations and, in my view, we are still often missing the point on quality. Quality is personal. It’s about the right care for me. Care that is clinically effective, safe and delivers the experience I want. Which is probably less lavish or demanding than we all fear…

“What does high quality care mean to you” It is a question we ask every new starter at LCH NHS Trust. You can see some of the answers in our gallery here or watch a video here.
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 It’s a question that the NHS England Consultation on the future of services “The NHS Belongs to the People” a call to action, needs to ask…..and we need to listen carefully to the answer.

It’s a question that we need to get right, and get the right people to ask too. Last week, our trust members interviewed consultant paediatricians. Junior staff members, parents and children interviewing doctors and having a real say in their appointment. The world has changed!  We have done the same with senior managers and consultants in rehab too.Our members are also engaged in driving quality through assessments of care environments, service improvement programmes and communication tests. Every one of them has something to offer and a view on quality. Want to join them? You can become a member here.

What does high quality mean to me? Well, I expect well trained staff, working in a team, supported by the best clinical evidence base in the world. Better IT and more convenience would be nice. kindness too. A recognition that I have a life and services are a guest in it. Above all, I want to be seen as an asset, not a disease or an issue. Because I reckon the NHS will need me to look after myself much more  in the future…..and everyone else too.

In an era of austerity, we should keep that focus. Because quality can be better, simpler and more cost effective. ……and if we engage people in the question, and delivering the services that result from the answer, we will have a chance of succeeding. That I hope will be one of the conclusions of the NHS England Consultation.

A quick bonus – here  is my favourite short video of the last year. It is all about quality. What’s the best thing about your care? “Being able to shave my own legs.” Fabulous words from Vicky in praise of Suzanne Henshall and the OT team.

Nana’s Golden Key

One of my colleagues was explaining last week why integration of health and social care is important. Tired of the usual cliches he decided to tell us what a carer had said to him. Let’s call her Nana. She described how her life had become blighted by the illness of her husband. How she had proudly resisted help until he became to much for her to cope with alone. She approached services and was given support. She said it was like

“I had been given a ring with 15 keys on it. But no-one told me which key opened which door. Or what was behind the doors.” It was frustrating and difficult. Then about a year ago services were integrated in one of our demonstrator sites.


She said “Suddenly I was given a golden key. It opened any door and gave me what I needed”.


Over the last two years, I have been writing about the risk of competition and fragmentation of commissioning on care. As part of a Future Forum submission, in briefings for the NHS Confederation, everywhere I could, I have worried about multiple providers serving multiple commissioners for a single patient journey leading to duplication and gaps. There has been a lot of change since. Those risks are receding.

Every day we hear about the importance of integrated services in the future NHS. The Government delivers a welcome £3.8bn pooled fund for integrated health and social care in the budget. Norman Lamb announced a number of “pioneers” to look at integrated health and social care systems – Leeds has submitted its bid along with, some say, around 100 others. Mark Britnell from KPMG – touted as future CEO of NHS England by the commentariat – writing in this month’s Health Services Manager says “Integration trumps competition in terms of delivering sustainable benefits”. Monitor sets out its thoughts on enabling integrated cares in its role as system regulator. The fabulous National Voices have come up with a new definition – at the heart of the vision in Leeds.

Person centred coordinated care

“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me.”

The integration lobby have won the argument, it seems. So why worry? Nana will get her golden key won’t she? Perhaps.

John Appleby writes in this blog about the role of the OFT and Monitor in ensuring appropriate competition. He argues well about the need to make a good case for not competing – with more than a golden key as support. The financial system still supports the delivery of funds to hospitals for activity or part funds urgent care to their detriment, depending on your view. Many agree it doesn’t yet support integrated care or continuity or shifts in care – good King’s Fund Report here.

Which leaves local leadership to sort things out. I have no problem with this. We must have faith in local System Leadership, which is essential in these circumstances. In Leeds we are working really hard to ensure that everyone plays a system leadership role. Our Health and Social Care Transformation Board helps to drive this. Its role in the integration of services has been fundamental to the progress to date. Local politicians have backed change. Commissioners have used the non-recurrent resources to fund change. Providers have thought about services first, not structures. Researchers have been working with us to assess the impact on quality and activity. Lots of detail here.

And change is beginning to happen. Beautiful, impactful, essential change. Change that happens in homes so is not visible enough. Change that transforms lives. Not enough yet to give every Nana a golden key but sufficient to be seen by those who matter. Take Elsie Sykes, one of our patients, talking about being “lifted” in the video on this page.


If you have watched this, you will understand why we must succeed. Because we all know an Elsie and we all have a Nana, don’t we?

What’s So Funny About, Peace, Love and Social Media?

Dean Royles asked me to write about Social Media for #NHSEngage earlier this week. I had already posted a blog about my twitter use on Digital Mental Health curator Victoria Betton’s site here. In it I suggested that Twitter was a gift to every leader and had blurred the traditional boundaries of leadership flattening hierarchies and increasing accessibility. It provided a wealth of resources that could be accessed, digested and shared. The blog seemed to go down pretty well and I had much feedback.

There is a great Elvis Costello cover of an old Nick Lowe song that you may have heard from 1978.

“As I walk through, This wicked world
Searchin’ for light in the darkness of insanity.

I ask myself, Is all hope lost?
Is there only pain and hatred, and misery?

And each time i feel like this inside,
There’s one thing i wanna know:
What’s so funny ’bout peace love & understanding?”

This came to mind when I was asked to write about social media. The song is a plea to think differently and imagine a different world, one where many people aspire to live. This seems to me to be relevant for how social media has been and should be viewed in the 21st Century for the NHS. A world of effective digital consultations; on-line peer support; sharing of expertise and knowledge…..all of these are happening somewhere now. 

An insight that I picked up at a recent Trust Development Authority session for Chairs and Chief Executives is relevant here. If you want to change someone’s behaviour, you first have to change their mind. Colin Price of McKinsey suggested this needs four things to be in place…COlinPrice

  1.  A compelling story
  2. Processes and structures that reinforce
  3. Skills required for change
  4. Role modelling

So, if we want to embrace social media, we need to look at changing mindsets to change behaviour. This model helps me frame what I think.

I also learned that the impact of role modelling is as strong as the other three put together.

There are many people who role model Social Media use and a compelling narrative is emerging through #NHSengage. Colleagues and peers have published erudite, thoughtful and impressive pieces on the use of Social Media. I found myself nodding along to everything Dr Mark Newbold said; saying “I do that” whilst reading Lisa Rodrigues’ piece; and reflecting on how far things have progressed when reading Dean’s piece on driving a permissive culture on social media.

We are much less well prepared with reinforcement mechanisms and skills. Plans are patchy. Mechanisms can restrict instead of free up practice. My own trust is wrestling with this at the moment. Trying to forge ahead, learn from others and not make too many mistakes. But it is tough. And perhaps one of the most powerful pieces on how much more is needed was that written in October 2012 about social media and health and wellbeing from Claire Jones  – this is a must read for people wanting to understand how social media can improve access and the steps that need to be taken if this is to be the case. For example:

“People with disabilities and long term conditions are already using digital and social media to support them and to help them maintain or improve their health (Malby and Mervyn, 2012). They are doing this independently and “under-the radar” of services, because services are not set up to accommodate or encourage this. The irony is that internet use is seen on care planning documentation throughout Leeds to be considered a luxury item, not an essential for planning care and accessing our community; this has to change for the planned changes to be possible.”


“We consider that building capacity within this population to use digital technology could be considered a priority area. Access to information and skills training sessions, through libraries, community groups, mobile libraries, and access to useful directories of apps and software, and information about how to access funding for computers and online access are identified as important ways to support the population of Leeds to utilise digital and social media solutions.”

My belief is that you could replace the phrases relating to people with staff and they would also hold true. Developments like professional chats – #nurchat #ottalk #ldnurchat #wenurses – arose because staff decided with support from Social Media innovators like @wenurses that a place to talk and share was helpful. Professional #tweetmeets are starting to occur. Training is springing up through everyone from Leeds and York Partnerships FT to Inkwell Arts. 

What could we do with a decent investment and focus in building systems, processes and skills for staff and patients? We have the role models and narrative. Let’s create the rest of the requirements to improve at scale and pace. In a 21st Century NHS this is essential …..and ask yourself “What’s so funny ’bout peace, love and social media”

Note – all content in this Blog came from my experience or directly from Social Media sources. No paper or phones were harmed in the making of this blog.

Civil War, Heart Failure, Sex and Big Data

The World Economic Forum report published earlier this year sets out the issues  affecting healthcare across the globe over the next few decades. At it’s heart are three assertions. To become sustainable, health systems are going to have to focus on:

  1. The use of “big data”
  2. The way places affect the health of people
  3. Seeing  patients as assets not problems

These are themes close to my heart. You can see the full report here.

Today’s blog focuses on the first issue data and using “Big Data.”

I was lucky enough to be asked to open Big Data Week in Leeds a couple of weeks ago. This was a great intiative looking at how different groups can bring data they have together to drive insights about how healthy Leeds is. A sort of Joint Needs Assessment with a twist. Details here. My talk covered the importance of transparency, the power of data to bring clarity, insight and intelligence; and big data and the future of Leeds.

The importance of transparency. In 2006 I was leading a review of the Department for International Development on behalf of the Cabinet Office. Part of the review required trips to areas of conflict. We ended up in Nepal, where a “low grade” conflict based on ethnic lines was rumbling along. At a remote school in the Himalayas, we were greeted by the headmaster and local officials. The school was part of the aid programme. Along the walls were details of the children, their cultural roots, their attendance and grades. This was transparency in action, if a bit hard on the kids not doing so well. I asked the head about the approach. He talked about the importance of transparency and accountability to the local community. It was powerful stuff.

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“The rebels came to see us one day. They asked for a contribution to the cause. Violence lay behind the threat. I pointed to the walls. I told them that their children were in school as much as anyone. They had as much resource and the same books. And that they were getting good grades too.

I asked whether instead of us giving them money, perhaps they would make a contribution to the school.”

“That was brave!” I said.

Yes. I had also called  the army so knew they were on their way. Data are strong but a contingency was essential”

Data can be presented to bring clarity and impact. Chris Bentley’s work on health and primary care undertaken in 2010 showed clear and stunning disparities in health. He looks at how access to primary care and the support for chronic disease management affects patients.


In Birmingham, for example, you can see that according to GP lists, the prevalence of heart failure was higher in the outer areas of the City. (See map on the above left)

If you look at mortality data, you can see that mortality from heart failure was highest in the inner city (Seemap on the right). The data reveal that we need to look at why patients are not accessing primary care until too late.
This then requires us to look at the insights – is it the way services are designed? The attitudes of patients? Doctors? Similar analysis appear in other parts of the country and link to the inverse care law – I am not picking on Birmingham, justusing it to illustrate a wider point!

Using multiple data sources, real insight from patients, segmentation and analysis we can begin to make a difference.

Intelligent data can bring insight. Patients can make very rational decisions. We often just don’t like them.

As a commissioner, one of my targets was to reduce teenage pregnancy. The long term trend was down and numbers were small. However, the were a few areas of hotspots. The public health team analysed a range of data. These suggested that the hotspots clustered around a couple of schools. They also found that access to pharmacy was limited around those schools, particularly on a Friday evening and Monday morning. Insight from teenage girls suggested that they needed to be able to access prophylactic and emergency contraception at those times as they knew they may end up drinking too much and taking risks. We might not like this but by looking a pharmacy access first, then attitudes to sex and relationships, we could consider how we further reduce teenage pregnancy.

Big data are the future – as set out in the World Economic Forum Report. The multiple factors of innovation, economic problems, demography and expectation need data, intelligence, insight. We certainly believe this in Leeds and are placing this at the heart of our Leeds Innovation Health Hub. More details here.

All health partners, the universities, the council, local industries and the national bodies based in Leeds have signed up to our ambition to make Leeds a global city for health informatics. We believe the conditions in Leeds make this a unique place to make this a reality. The blurb on the press release says, we have:

  • More focus on clinical leadership in the NHS will drive up quality, improve health outcomes and enhance the patient experience
  • The city is in a unique position as home to academic expertise, public and private healthcare organisations, national NHS infrastructure and wider city technological and business sectors
  • Patients will be empowered to take increasing control of their health through better access to their own data to inform their decisions
  • Healthcare investors to Leeds will be able to test concepts to ensure they are widely deliverable
  • The ecosystem will support a focus for inward investment leading to economic growth and to become a partner of choice for local, national and international businesses wishing to innovate in the health sector

And why not. Leeds has more health informaticians per square foot than many cities in the World – a function of having the national programme for IT, the NHS Information Centre, NHS England, Health Research in health institutions and the two universities, the two largest providers of primary care  IT, insurance companies….. Marry that to a city leadership that is trying to focus on communities; that has good progress on risk stratification of patients, supported self care and integration; and wants to be the Best City in the UK; and we may just get there.

So, big data are the future. Our lives are already shaped by this in how we shop, eat, travel, communicate…..industry is ahead of us in this regard. We need to catch up, overtake and use big data, place and people’s assets for a sustainable NHS.

As the Chief Executive of Leeds Community Healthcare NHS Trust, I want us to be a part of these changes. For my organisation and for the people we serve. Because the realities set out in the World Economic Forum Report will come all too soon.

Thanks to Peter Laflin for the invite and everyone at Big Data Week 2013.