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Martin McShane: Large scale change

10 Apr, 12 | by BMJ

Martin McShaneOver the last few weeks my reading and listening has made me consider whether we are at a crossroads in understanding and agreeing the purpose and nature of healthcare. Let me start with this quote from the evaluation of the 16 integrated care pilots that were supported by the Department of Health:

“Over the past 50 years healthcare systems have been focusing on strengthening acute care sectors to respond to the needs of patients suffering from life-threatening conditions such as heart attacks. Thus, healthcare systems may not be well equipped to respond to the needs of increasingly older patients suffering from multiple chronic conditions and who require a combination of regular primary care support with both predictable and unpredictable specialist care. The goals of care for those with chronic and/or disabling conditions are not to cure (as is the case for acute conditions), but to enhance functional status, minimise distressing symptoms, and prolong and enhance quality of life through secondary prevention. It is clear that these goals are less likely to be achieved through traditional approaches to care that focus on individual diseases and are based on a relationship between an individual health/social care service-user and a single health/social care professional.”

It appears to me that we continue to labour to try and make a system work, for which the context has so fundamentally changed that it is destined to fail. It feels as if a truly radical approach is required. This feeling was reinforced as I read a paper calling for a revolution in social and professional attitudes and beliefs about health and social care. Perhaps what is needed is to stop trying to make the old system fit the new paradigm. Instead we should articulate the need for a change in social attitudes, change the training and ways of working of health professionals and create a policy framework that supports transformation and accelerates innovation across the system.

The difficulty of such an approach cannot be underestimated. It came as a shock when I first read (some time ago), in Crossing the Quality Chasm, that “Scientific knowledge about best care is not applied systematically or expeditiously to clinical practice. It now takes an average of 17 years for new knowledge generated by randomised controlled trials to be incorporated into practice, and even then application is highly uneven.” The publication of a report setting out how the NHS could set about accelerating the adoption of innovation and best practice is welcome but may get shoved aside and ignored in the tumult of reform. That would be more than unfortunate, as focussing on the how is something to which we must surely give greater emphasis.

Given the importance of “how,” the evaluation of the 16 integrated care pilots is a fascinating and well written report which carries a number of significant messages, the most important of which is, “it was too early to identify impact within the timescales of the pilots.”  Having been involved in a number of large scale change management initiatives over the last twenty years I recognise that two years is just about enough time to “warm up.” Large scale change takes time, continuity of care, and resilience. Most of all it needs flexibility and adaptability. This last point was highlighted in one of the eclectic range of podcasts I get to listen to as I travel across Lincolnshire and beyond, to meetings. This one discussed the problems associated with the National Programme for IT (NPfIT). A large scale, top down, highly prescribed programme of change in a complex context is fraught with risk. The lessons from what happened to the NPfIT need to be used to avoid more of the same.
Sitting in what used to be the Professional Executive Meeting—but is now a meeting  of seven organisations—the four Clinical Commissioning Groups, Local Authority Public Health, Commissioning Support Services, and the remnants of the PCT Cluster—I ruminated on what lay ahead. I hope that the principles, being driven by the reforms, of creating accountability for use of resources across Primary Care and a drastic culling of management costs will help deliver what is needed. It is a big ask and large scale change needs not only time, continuity of care and resilience but, right now, it needs a large dollop of optimism!

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.

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  • Charles Heatley

    You are right about the need for change. GPs need to accept that their teams need reconfiguring so that they spend a lot of their time making complex decisions about complex situations, giving more autonomy to nurses to do the long term condition management for less complex patients.
    However a key role in any team is that one person does have a relationship with the patient, particularly when the decisions have to be made from a holistic perspective. We lose the relationship with patients at their and our peril.
    Kieran Sweeney’s work on complexity has a lot to offer.

  • R Papagheorghe

    Indeed, in the Plan-Do-Check-Act process there is a leak.
    We, doctors and medical system leaders like very much to plan ; if someting does or does not work as we like, we plan something else. Most of us are fond of DO, as well, because we are practical people, (sometimes we like just to see what it gives). At the point of CHECK I presume we are very much biased or pressed by all kinds of interests, mostly (corect me if I’m wrong!). Therefore, when the ACT must be done it is based on unreliable results. This is a process with hystoric applications, not somebody’s fault in particular.
    But, indeed, we must adapt and this is a hard job.
    dr. Raluca Papagheorghe
    Microbiology
    Romania

  • Munir (Munir) E Nassar, M.D.

    Good comments by Mr. Martin McShane, NHS, with his  refreshing approach to solve the deteriorating health care system.
    I have stated in more ways than one that fitting the old health care monitored practice to a new and changing social culture is fraught with many obstacles bordering alas on no solution whatever. My comments relate to health care in the U.S.A. mainly:
    Unless the emphasis on “business” of health care  for profit to third parties is removed from the equation and the increasing emphasis on technology and research replacing
    clinical medical practice one on one doctor -patient relationship is changed, I see no real future for clinical practice as it used to be practiced in older days.
    I am not against medical reaerch progress but the latter should be relagated to a certain % of bright young students only and the majority of students encouraged to study and practice clinical medicine.
    Perhaps eventually a balance maybe reached between”effective” medical practice, research, and the importance of clinical practice.
    Mounir E Nassar, M.D.

  • Martin McShane

    Thanks you for the comments, which I appreciate. 
    We will need to disagree over context. The level of frailty and complex co-morbidity challenging health systems world-wide does appear to have some pretty strong evidence. 
    I have been in conversation with people since writing this and I wonder if the generic adoption of quality improvement tools by the medical profession would help? The productive General Practice programme gets some very positive feedback from colleagues who have been cynical about change in the past. 
    http://www.institute.nhs.uk/productive_general_practice/general/productive_general_practice_homepage.htmlSomehow we need to break away from a didactic form of management which alienates the professions and seems to generate quite odd consequences for patients. The current NHS reforms present an opportunity to do that – possibly?Whatever we do, doing more of the same isn’t going to meet the challenge of changing expectations across society, new technology and treatments creating new demand and no growth in funding for the foreseeable future.

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