Diary & Blog w/c 19th May 2014

 A packed and very stimulating week - Peter Fuda's insights on transformative leadership are a powerful mix - based on strong field research but also intuitively right - the way the best new ideas change your thinking, but then feel so self-evident you wonder in hindsight why they didn't occur to you. Sadly, I had to miss the Kings Fund event on leadership, as some complex service and financial arrangements with a provider had to be finalised.

Our first Integrated Care Programme Board set the right tone by having commissioners, providers, and stakeholders round the table from the outset, and we have our six most urgent projects initiated as we start to eat a very large elephant in a series of bitesize chunks (focus on these six, get them done, and don't think too much about the other 50 in the queue). First up:


  • Identifying those patients at highest risk of becoming acutely unwell (risk stratification)
  • Developing a secure cloud based system for uploading care plans so patients & HPs can access 24/7
  • Developing a community rapid response service for health and social care
  • Enhancing Primary Care support for nursing homes 
  • Increasing number of patients able to remain at home at end of life
  • Urgent review of intermediate care services to enable smooth discharge and best possible recovery after a stay in hospital


But the pick of the week was Friday - an excellent forum from NHS England & Macmillan on 'Commissioning for a Better Patient Experience'. The session used actors to explore patient stories in rich detail, and made good use of IT to share the thinking from the workshop tables in real time. I was part of the 'Stress Test' Table - senior people from NHS England across patient experience, commissioning, and contracting, plus the PE Director from a Provider Trust in the North East that has been doing some really impressive work on using patient experience to systematically improve the quality of care. Our job was to gather in the ideas from the five main tables and provide challenge, feedback, and try to develop concepts into something that commissioners could act upon.

Patient Experience is an underused resource in the NHS, partly I think because its importance is consistently misunderstood. Too often it is perceived as the equivalent of a comment card at the end of a meal; useful to check people are happy with the service, but an optional extra when compared to whether the food is hot and fresh, bookings are coming in, and the till is making all the right noises. I would argue that PE is actually one of the big three measures for the success of our health system, alongside the health outcomes of care, and value for the taxpayer, especially if we think much bigger than the Friends and Family Test.

Beyond the obvious and most serious example of Mid-Staffs - where patients had serious safety concerns but were not listened to - there is huge scope for using patient experience as a safety monitoring and alert system. Patients and their families may not be familiar with detailed safety standards, but they know when somewhere isn't clean, or when basic needs for food, water, pain control, and comfort aren't being met. If tools like 'Patient Opinion' were in widespread use by patients we would quickly identify areas of concern.

And in addition to what patients report, are there behaviours that might warrant attention - 'red flags' that warn of a possible problem? There might be good reasons why a patient discharges themselves against medical advice; or accesses Primary Care, Walk-In Centre, and A&E all in a 24 hour period; but it might also highlight a lack of confidence in care. If we invested more time and resource in asking systematically about the experience of care - what happened as much as how satisfied there with what happened - every patient becomes an inspector, safety and quality are enhanced, and the QA responsibilities of commissioners and regulators may start to feel achievable.

Beyond assurance, the intelligence can be used to drive improvement. I have never met a health professional that doesn't want to provide the best care they can, and I have never met an NHS or Social Care Manager who doesn't want to change services for the better. The debate with commissioners is almost always about the constraints - money, workforce, rules - but never about the desire to improve.  There's a real and very rational nervousness for individuals and provider organisations about the idea of having a public running commentary on the care provided, but once embraced as an improvement tool it can be incredibly powerful. Some providers are already using patient experience feedback to inform staff appraisals, provide quick feedback to care teams, and to direct and measure system improvement.

For commissioners there are further opportunities beyond assurance and improvement - patient experience information could inform the 'wrong care delivered well' problem. A high satisfaction score for an urgent care episode won't identify gaps in community services that created the emergency, but patient stories can inform every stage of the commissioning cycle. We can use this intelligence to plan, design, and mobilise new pathways and services by working in partnership with the patients who use services now, and use this same intelligence source to measure change as new services come on line.

The session on Friday will be part of a longer conversation that will produce national policy and potentially guidance or service frameworks for commissioners to implement. In the meantime commissioners can act now, by including Patient Experience as a key part of provider quality schemes and quality incentives. In Norwich we are working to embed 'Patient Opinion' into all Provider contracts, asking them to promote its use, respond to stories, and use the feedback as a quality improvement tool. Here's the Norwich feed - most of the stories are reports of great care, and I check in every day to read and tweet them.

Final word from Peter Fuda. There was a timely contrast between leadership based on fear and building a sense of crisis - the 'Burning Platform'; and that based on mobilising people's internal drive to excel - the 'Burning Ambition'. Inviting many more patients to share their experience of care might initially be a little frightening, but it ultimately taps in to the burning ambition of every NHS professional out there. We all want to do the best we can for patients; we just need to ask more patients for help.