David Pencheon: Learning to learn comfortably

David PencheonI have had two distinctly different learning experiences this week. First, for 48 hours in a summit of NHS managers, clinical leaders, and others in a posh hotel, and secondly, this morning, lying in the bath, listening to podcasts of Chris Ham, Muir Gray, and other visionaries. Both were rewarding and from both I learnt a lot.

At the conference, we learnt that public surveys on the NHS were revealing: “the public has spoken, but we are not quite sure what they have said”, and, on rising public expectations of the NHS, was it not Anne Widdecombe who said that we expect more of Government than of God? (and why not?)

Ten themes emerged about how we could ensure a bright future for the healthcare system:

1. create systems where genuine integration flourishes (at all levels and interfaces);
2. give people and organisations the system and the permission to take and share risk. Clinicians and managers can be both equally effective at lowering mortality;
3. don’t salami slice your way out of trouble – it never works – radical challenges need radical solutions. If we do more of the same (even if we do it a little more efficiently) we’ll get the same output (a little more cheaply and no more sustainably);  the improvement of stroke services happens by a systematic, clinically led, and industrial approach to quality, not by hoping (or praying) that localism might deliver it;
4. don’t think you can improve things without closing something (as always, it’s not what you start doing that’s technically tricky, it’s what you stop doing that’s politically almost impossible) – don’t masquerade a short term unpleasantness as a story too difficult to tell.
5. if we really agree that major change is needed for a sustainable health service, we should use what is perceived by many as a major crisis to enable that change to happen;  (i.e. never waste a crisis: short term revolution for the sake of long term evolution);
6. commissioning has got to be the key in one shape or another. Remember Ghandi’s view of western civilisation: “it would be a good idea…” Replace the word civilisation with the words world class commissioning. We need to address: size, data-sharing, risk-sharing, and models of care; 
7. ensure the key partners are the public – the benefits of a far more enlightened involvement of the public and patients in health improvement and health care far outweigh the risks. We need to demonstrate a positive future so well that the public will be demanding a health service that is not over focused on large general hospitals. Successful and sustainable companies are that because they listen to the people they serve and act on what they hear. We know when we will have been successful when every patient feels comfortable to ask every professional whether they have washed their hands;
8. ensure that, whilst focusing on patient experience and health outcomes, we (or perhaps ministers in the Department of Health) don’t throw out the baby with the bath water and forget all the other important roles of the health service such as systematically high quality processes, addressing inequities, and being a socially valuable, responsible, and future proof set of organisations.
9. collaboration and competition can be healthy bedfellows. It happens all the time, and happens best when it is done on the basis of high quality and highly accessible information.
10. Be bold and visionary:  don’t ask for better candles or better carbon paper, instead ask how we can survive and thrive in a low carbon world. Delivery is the key: saying it or wishing it won’t necessarily make it happen.

Neat ideas maybe, and although there was wide agreement on these principles, there was a distinct lack of specific strategy on how we all make this journey together. Of course there is lots of evidence that local examples of any of these initiatives can work, but precious little evidence that anyone has the courage or vision (or indeed permission) to try this all at a system level.

What seemed to be lacking was, not the technical adjustments that can and need to be rationally applied at a local and at a system level, but the compelling narrative that will ensure that everyone from public to ministers can visualise a future NHS worthy of the name. Perhaps the most important picture to paint we decided was how we can address that most challenging of interfaces: between primary and secondary care – a divide we may unfortunately perpetuate by talking about it in such terms. If integrated care organisations that serve the needs of the public are to work, then staff and buildings (from secondary care, social care, and the third sector) will need to revolve around the needs of people in communities and primary care – and the regulatory and financial incentives (e.g. tariff) must support this. This seems the only way we will get high quality care, with better health outcomes, and improved patient experience within a context of social, financial and environmental sustainability.

The building blocks are there and we may even have the vision and courage within managerial and clinical leaders – but will the forthcoming White Papers facilitate its delivery?  Otherwise it will be a perfect storm of financial squeeze, increasing patient, professional, and industry expectations and another round of overcomplicated and ineffective regulation on a scale like we have never seen before.

Good learning all round?  Of course, although as Socrates would say, perhaps the most powerful way of learning is to reflect deeply and regularly – a life unreflected being a life unlived.  The most important thing I learnt was that although it may be easier to interact with peers at conferences, it’s sometimes more comfortable just to listen and reflect in the bath. Better than both is to walk resolutely towards the sound of gunfire, wearing more than a bath towel…