3 Ways to Create Trust

How do you create trust?  Is it even realistic to think that organisations that are competing with each other for increasingly scarce resources are going to be able to trust each other enough to allow credible whole system plans to be developed?

Joint working is essential, but the barrier to it often boils down to one of trust.  Do the CCG and council trust each other enough to pool budgets? Do the hospital and the CCG trust each other enough to enter a risk sharing agreement?  Do general practice and community services trust each other enough to build a single staffing model across a locality?

This can become a chicken and egg type scenario: we don’t trust each other enough to have a single health economy plan rather than a set of organisation specific plans, and we can’t develop trust because we are not working together closely enough.  So if trust is the secret ingredient, how do we create it?

Well I don’t claim to know the answer, but I was at a session with the previous NHS Confederation chief Mike Farrar recently and asked him this question.  His answer was so good that I thought it only fair that I share it with you!

He said that there are three ways to create trust.  The first is to agree a shared sense of purpose.  He said that many health systems do not put enough effort into this.  A system plan is produced, it goes to a whole system meeting, and is generally agreed.  What doesn’t happen is a stress testing of the purpose or a putting it under the fire of different scenarios.  Organisations don’t take the aims of proposed whole system plan back to base and work through with their Boards as to how the goals of the system can match with the goals they have set for their organisation.  More effort here, according to Mike, is an essential foundation to building trust across the system.

The second is to establish system wide clarity on the approach to competition or collaboration.  There needs to be a shared understanding as to how this will work across the health economy.  What doesn’t work is asking groups of clinicians from all organisations to work together to design a new model of care, and then the CCG springing a procurement on the providers that is not expected.

This does not mean that the CCG has to say that they will not be putting any services out to tender or that they will be procuring everything.  What it means is that a framework is established so that everyone is clear when services will be procured and when they will be developed through collaboration.  The rules of engagement need to be clear and signed up to by all partners.

The third is to establish who the system arbiter will be.  Given the challenges that all health economies face it is inevitable that there will be issues on which organisations do not agree.  It is not good enough to simply say that decisions will be taken that are in the public interest, because this can often be argued both ways. 

There needs to be agreement as to whether deviation from the collective agreement is ever acceptable, and if so in what set of circumstances.  Systems must establish an agreed point of arbitration, which everyone signs up to before such a situation arises, and which everyone agrees to abide by when a decision is made.

Trust is a critical but elusive ingredient of effective whole system working.  The current environment and the challenges that we face dictate that there is not enough time to spend years building it up, but what I think Mike’s answer has provided is a set of actions that systems can take now to make their 5 year strategies much more likely to deliver.


As CCGs consider their 5 year strategies to improve health outcomes and ensure maximum return on NHS funding, one of the questions that arises is whether we should incentivise individuals to be healthy. 

In South Yorkshire and Derbyshire a pilot scheme offering mothers £200 in shopping vouchers to encourage breastfeeding has been set up.  Breastfeeding has been shown to reduce cases of stomach problems, asthma and other respiratory conditions.  The business case is relatively straightforward: the cost of the incentives will be more than outweighed by the benefits realised later on. 

So is this, and other schemes like it, an approach that CCGs should be rushing to adopt?  Does the business case stack up, both on outcomes and financially?  Well there are other examples to learn from.  In 2009 a weight-loss scheme, Pounds for Pounds, was set up in Kent which offered participants cash payments of up to £425.  Less than half achieved significant weight loss and a high drop-out rate meant that evaluators were unable to recommend it as a way of tackling obesity.

However, a stop smoking scheme in Dundee had more success.  The NHS there ran a two-year programme offering smokers £12.50 a week to quit smoking.  By the end of three months, nearly a third of participants end up kicking the habit, more than twice as many as other smoking cessation projects achieved.

There are a number of arguments against this type of approach that I don’t intend to go into here, such as whether it creates perverse incentives, whether it is patronising, and whether it will simply result in paying people for something they were going to do anyway.  But there is one point that I do think is particularly important, and this is best made by Harvard University political philosophy professor Michael Sandel.

Professor Sandel’s lecture ‘Why we shouldn’t trust markets with our civic life’ (you can find it here) tells the story of a Texas policy that awarded children two dollars for every book they read.  He then asked the audience what they thought of the approach, and in discussion concerns were raised about the impact on the long term motivation of the children to read.

Sandel’s argument is that, when considering non-material goods, market mechanisms (e.g. putting a price on something, or using cash incentives) can actually change the nature of the goods. So if we pay children to read books, it can change their motivation to read and the types of books they read.  A key outcome of the Texas study was that children read shorter books!

He says that economists assume markets are inert, that they do not change the products that undergo market exchanges. This is likely to be true for material objects. However, for non-material values like learning and education and health, this is not true.  For us this means that the value of stopping smoking or breastfeeding or losing weight actually changes if we pay for it.  We risk eroding the intrinsic value of these things by paying for them.

For health the unintended negative consequences could be serious.  Will intermittent smokers start to smoke in order to receive the incentive to stop smoking again? Will obese people become morbidly obese to receive the incentive payments to lose weight? More importantly, will the value placed by individuals on their own health become a function of the return they receive for it, rather than something held as valuable in its own right?

Sandel himself says, ‘It is not about inequality and fairness but about the corrosive tendency of markets. Putting a price on the good things in life can corrupt them. That’s because markets don’t only allocate goods; they express and promote certain attitudes toward the goods being exchanged. Paying kids to read books might get them to read more, but might also teach them to regard reading as a chore rather than a source of intrinsic satisfaction.

‘Some of the good things in life are degraded if turned into commodities. So to decide where the market belongs, and where it should be kept at a distance, we have to decide how to value the goods in question—health, education, family life, nature, art, civic duties, and so on. These are moral and political questions, not merely economic ones. To resolve them, we have to debate, case by case, the moral meaning of these goods, and the proper way of valuing them.’

So for CCGs this approach is not something that can simply be adopted.  As leaders with responsibility for population health we need to carefully think through all the decisions we make, and the consequences that these will have not just on the balance sheet but on society as a whole.  Health and wellbeing boards are the perfect place to ensure these issues are fully debated on an individual basis, and it is our duty to ensure that this happens.


Something Has to Change

If we carry on down the same road we have been down every previous year, with providers operating in isolation from other providers and CCGs operating in isolation from all providers, where will we end up?

If each organisation continues to develop its own plans then it plays out something like this.  Providers and CCGs enter the contracting round with the figures they need out of the contract.  They argue about the likely success or otherwise of demand management plans.  With the deadline imminent they agree a figure on paper, but they both take away different assumptions about what will happen during the year.  The CCGs assume demand will be reduced, the providers assume demand will grow. 

The net result is a deficit gets built in to the health economy position, because both build different assumptions into their forecast outturn position.  Someone will be right and so a deficit will inevitably sit somewhere.  The value of the agreed contract figure becomes material only in terms of determining the level of monthly cash payments.  In terms of establishing an agreed end of year position it is virtually meaningless.

In 2014/15 the gap between what CCGs can afford and what providers will require is going to be bigger than ever.  Aside from ever increasing demand and inflationary pressures, the situation is exacerbated by the planning guidance.  Now we have the cost of introducing seven day working, the requirement for CCGs to fund £5 per head for general practice, the need for CCGs to keep 4% out of recurrent expenditure (2.5% non-recurrent, 0.5% contingency, 1.0% surplus), just to name a few.

Once a figure is agreed on paper and the year starts, the cracks will start to appear.  CCGs facing financial challenges will shift down a route of increased contract challenges and reducing elective activity, and providers will try to do the reverse (improve coding and increase elective activity).  Throw in the last winter before a general election and the pressure will ratchet up, and relationships will become extremely fraught.  And if next year does not finish us off the year after will, with the transfer of funds from providers to social care via the Better Care Fund.

But there is an alternative.  We could work as health communities to have a single plan.  We could work together to take the resources that are available (knowing that they are insufficient) and use them collectively to deliver a single plan.  This requires each organisation to relinquish the sovereignty that it feels entitled to; actions would be determined by the greater good, not simply by what is best for any single organisation.

In this model organisations collectively commit to what the health and social care economy must deliver.  There is a single set of assumptions that all sign up to.  Agreement is made as to how the money will be used between the organisations in order to enable delivery of the plan.  The contract negotiations focus on this, rather than simply setting the level of cash flow. 

The alternative is harder to set up.  It requires providers to work with providers and CCGs to work with providers.  It will fail if alongside the one plan organisations have their own (secret? real?) plan.  Each organisation has to commit to the system plan.  Each organisation has to be accountable to each other for delivering their part of the plan. 

Clearly this requires trust between the partners. It introduces an uncomfortable interdependence.  If one organisation does not deliver, all will suffer because delivery of the overall plan will suffer.  And of course the worse the current position, and the longer we continue along the current course, the less trust there will be.  If we wait until we trust each other to do something different, we may never get started!

There is no doubt this alternative is harder to set up, but if we understand where the route we are currently on takes us then maybe we will think it is worth it.  After all, something has to change.


Clinical leadership sits at the heart of the thinking behind the introduction of CCGs.  But as a result great expectation and great responsibility has been placed on the GPs who have taken on leadership roles in CCGs.

These are not easy jobs.  There are a number of complex elements to them that we have explored in previous posts on this site:

In ‘the importance of localities’ we established the need for those GPs leading localities to build the relationship with member practices,

‘The relationship between the CCG, with all its statutory responsibilities, and its member practices, with all the pressures they face, will be a critical success factor for the long term success of CCGs.’ 

In ‘8 top tips to drive GP engagement’ we identified that beyond developing the engagement of member practices a key role of GP leaders is to influence individual GPs, and that achieving this is no mean feat. 

Beyond that we determined in ‘CCGs are redefining out of hospital care’ that GP directors in CCGs have a key responsibility in the transformation of these localities around a redesigned general practice.

In ‘Is your CCG really clinically led?’ we established that GP directors have a corporate responsibility for the overall performance of the organisation and how it discharges its responsibilities,

‘An important question is whether the GPs on the CCG board are GP chairs – i.e. representing a specific group of practices or a locality – or are Clinical Directors.  The distinction is important.  A Clinical Director carries corporate responsibility for the organisation as a whole, including how areas such as finance and contracting operate.’

So in summary: build a relationship with practices, create an emotional connection between every member GP and the CCG, lead the transformation of general practice and community services, and take responsibility for the CCG hitting all of its statutory duties.

Can we expect our GP Directors to achieve all of this in 3 or 4 sessions a week?  Have we created undoable jobs?  Are we setting our GP leaders up for failure?  The public debate about GP directors has focussed on the potential for conflict of interests and how these are managed.  But it is missing the real question which is how realistic are the expectations we have placed upon these new GP Directors, many of whom have only been in these roles since April, and how are we supporting them to be successful?

And of course these GPs are primarily elected rather than appointed.  We give them the title of GP director, and then wait for the magic dust to descend and the great leader to emerge.  By and large it is sink or swim.  We are expecting leadership talent to emerge simply because they are GPs, without any structured development programme beyond that provided locally. 

There are examples of fantastic, courageous and highly talented GP leaders who are doing an amazing job and who provide inspirational examples of what is possible.  But how are we helping those for those learning the trade, who have taken on responsibility for leadership in the most testing time the NHS has ever known?  Doesn’t there need to be more: more structured leadership development, more visible support, more investment?  Isn’t this where we need those who are offering to support CCGs to focus their efforts?


Reading the planning guidance is always a treat(!), so it was very festive of NHS England to release this year’s guidance on Christmas Eve as a seasonal gift for CCGs and organisations across the NHS. 

It is a confusing time to be in the NHS.  We are so used to there being a plan dictated from above, and of taking on the job locally of putting this into place, that it can be quite disconcerting to receive guidance that reinforces that there is no overall plan for the NHS.  In the old days we received the ‘operating framework’, which described what local organisations needed to do to within the overall plan for the NHS.  We now have guidance ‘that sets out the need for bold and ambitious 5 year strategic plans’

It does claim to also ‘describe an approach to deliver transformational change’.  There is (inevitably) a framework (‘5 outcome domains with measurable ambitions, and three further measures of improving health, reducing health inequalities, and moving towards parity of esteem’), and then this strange concoction of ‘characteristics of transformational change’

These characteristics are by and large ambitions (e.g. ‘wider primary care, provided at scale’ and ‘a modern model of integrated care’).  They represent a direction of travel, but they do not of themselves constitute a plan.  In NHS England’s words they are the ‘characteristics’ of a plan. 

Of course NHS England does not claim to have a plan.  It is for local communities to use the guidance to create robust plans. ‘Plans must be owned locally and driven by local needs. Unlike previous years, this document is not prescriptive in how CCGs achieve this ambition.’ (p25).  So we are free to make our own plans locally.

But before we get too excited there are a few caveats.  There are 21 ‘fundamental elements’ that NHS England will use to assess the scale of ambition and plans for implementation, with 47 ‘key features’ to be demonstrated in plans.  These features include:

  • how you will enable primary care to operate at greater scale to improve access and continuity of care and to enable your urgent and emergency care network to function effectively’
  • ‘how you have considered your model of elective care for your local providers to achieve a 20% productivity improvement within 5 years, so that existing activity levels can be delivered with better outcomes and 20% less resource’
  • ‘how your strategic plans address whether your providers are seeing and treating a sufficiently high enough volume of patients to meet specified clinical standards, in line with the need to concentrate specialised services in 15-30 centres of excellence, linked to Academic Health Science Networks’

 The NHS has been trying to make these changes, or ones very similar to them, happen for a number of years.  But rather than tell you how to do it, NHS England is simply stating what must be done.  It is the freedom of how to get there that is the preserve of the CCGs.

But whereas previously funding has been available to smooth the delivery of such grand changes, the fiscal environment now offers no such support.  The NHS must save £30bn by 2021, and CCGs must operate within the financial rules handed to them.  These include a 4% non-recurrent requirement for next year (0.5% contingency, 1% surplus, 2.5% non-recurrent expenditure), rising to just over 6% with the money to be found for the Better Care Fund in 2015/16, with a 10% reduction in running costs in 2015/16 thrown in for good measure.

This financial pressure will hit providers, those that CCGs will be asking to support the delivery of these changes, hard.  Most providers already have very gloomy financial forecasts for next year, and I don’t think this guidance will have helped.

You may be thinking that this is beginning to sound like an impossible task, but help, it turns out, is at hand.  The ‘Any Town health system model’ is to be published in January.  This will show ‘how a typical CCG could achieve financial balance over the strategic period covered’.  Before you become too cynical about this please note that, ‘A number of ‘High Impact Interventions’ have been fully impact assessed and included in the report. Twelve ‘Early Adopter Interventions’ are also included; these have not been impact assessed to the same specification as the ‘High Impact Interventions’, but are innovative, cutting edge ideas which may be promising.’  Help, it seems, is at hand.

The big challenge ahead for CCGs could be working out how to make all of the pieces of the jigsaw laid out by NHS England in this guidance into a coherent local plan.  Or it could be finalising an approach that they believe will have the greatest chance of success.  In the little over 6 weeks that remain until the first submission, the question for CCGs is whether to focus on identifying how they will meet all 47 key features of the fundamental elements of the plan, or whether they should focus on getting local sign up and buy in to their approach to meeting the challenge ahead?  In the absence of a national plan, is stakeholder buy in more important than meeting all the requirements of the guidance? 

So in summary there is no overall plan.  The guidance is designed to help local plans be developed.  Whether it is ultimately a help or a hindrance remains to be seen.  Happy New Year!


What the impact of the Integrated Transformation Fund (ITF) will be is the question at the forefront of most CCG minds.  It is without question a huge challenge for all local health economies.

There are huge cuts to local government over the next few years.  As a result of this there will be significant cuts to social services, which in turn will impact on health.  Seemingly in response to this it has been agreed that the ITF (now apparently named the ‘Better Care Fund’, but let’s stick with ITF for now) will be established.

The ITF is a £3.8bn fund that seeks to pool existing budgets from April 2015 to enable greater integrated working and the transformation of local services.  According to NHS England and the Local Government Association (LGA) guidance a key criterion for its use is to ‘compensate for social care cuts’.

A critical fact here to keep front of mind is that this is not new money.  It works a bit like a visual trick: social care understand they are receiving an extra £3.8bn and health are under the impression that they still have the same money available.  The NHS, after all, has been ‘protected’ from any funding cuts.

So where then does the money come from?  The expectation set by NHS England is that it comes from the expenditure on acute trusts.    There are two routes identified for this.  One is an expectation that there will be further savings. David Nicholson has talked about the requirement for an ‘additional’ 2-3% productivity gains.  So in 2015/16 there will be a requirement for efficiency savings of 6-7% rather than 4%.  You can make your own judgements about how realistic this is.

The second route is through the benefits that integration realises.  The theory is essentially that if health and social care work together and create new models of care that keep people healthy in the community then admissions will go down and delayed transfers of care will be removed.  But this of course sidesteps the starting point for all of this which was cuts to social care.  The money will at best protect the total current expenditure in community health and social care.

So in reality there will be no new capacity to enable the huge savings required of acute trusts.  Instead the new ways of working through integration will be expected to deliver these benefits with no additional capacity.  Herein lies the key problem that the ITF is creating: it is generating expectations of investment in community services that are not real, and using these expectations to justify the requirement for reduced expenditure in acute hospitals.

So how can CCGs respond?  There are probably two tactics available.  The first is to do everything possible to protect health expenditure.  CCGS can use the absolute minimum possible to be part of the fund, insist wherever possible that the funds used come with clearly badged expenditure, and try to limit the damage that this is inevitably creating.  CCGs could make a judgement that based on the experience of other nationally imposed financial constructs (e.g. MRET) that the incentives will not generate the changes expected, and proceed on that basis.

The second is to recognise that the only actual change proposed within the ITF construct is the integration of health and social care, and so to develop a plan that will maximise the impact of integration.  This then take CCGs into questions of scale, on the basis that the more that is integrated, the bigger the potential benefits (whilst at the same time recognising the bigger the potential risks).  The questions then for CCGs are whether they are prepared to commission all of community health and adult social care with local authorities on a whole system basis?  Are they prepared to create a single commissioning function for this that would incorporate planning, quality and contracting?  Or if not how far are they prepared to go?

Difficult choices ahead.  These choices are compounded by the timescale: the draft ITF plan is due to be submitted on the 14th February.  And we are already well into the contracting round for next year.  Acute trusts are quite rightly going to want to know what the plan is for the ITF ahead of any agreement, particularly any two year agreement.  Unfortunately there are not any straightforward solutions.

Merry Christmas to all, and a big thank you for all of your support and encouragement for this blog throughout the year!


Much has been written about maggots this week, but those involved in the maggot business are so concerned with the lack of balance in the reporting that some are thinking about getting out altogether.  So is it time to get out?

At their most basic level, maggots are the larvae of flies, but as you and I know, they are so much more than that.  For a start nearly all fish love maggots, and for them they are a great source of food as well as being effective bait.  Fishermen are even prepared to pay for them: at WillysWorms.co.uk they go for £2.48 a pint.

Live maggots have been applied as a medical treatment since antiquity, as an effective means of wound treatment.  The late Princess Margaret is possibly the most famous patient to receive ‘larval therapy’ which involves using sterile maggots to clean an infected wound.

And forensic scientists use the presence and development of maggots on a corpse as a way of estimating time elapsed since death.   So called ‘entomological evidence’ was first used to convict a murderer in 1935 when Dr Buck Ruxton was found guilty of the murder of his wife and maid based on maggots dated at 12-14 days old.

But despite their really positive contribution, the business of maggots is getting increasingly bad press.  They are, it seems, becoming something of a problem. 

In August a Worthing woman discovered a maggot in a burger that she bought from McDonalds.  Apparently she wasn’t loving it.

In November cousins Ella Grix and Chloe Appleford were about to take a spoonful of Weetabix, when they were, according to the Worthing Herald, ‘horrified’ to look down on their chocolate-laden biscuits to see maggots crawling in and around them. The girls’ grandmother, Yvonne Read, 45, had bought the box in Gravesend, Kent.  ‘I will never buy or eat Weetabix again. It was disgusting,’ a dismayed Ms Read told the Herald.

Stories like this are just the surface of it.  There are a number of horror stories also doing the rounds.  In July the Independent reported this story, one that the more squeamish amongst you might want to skip.

Derbyshire resident Rochelle Harris had just returned from a holiday in Peru when she began developing shooting pains in her face.

The 27-year-old initially thought little of it, and assumed the problem would quickly disappear, but the following day she  woke to find a strange liquid covering her pillow and began hearing scratching sounds coming from inside her head.

Increasingly concerned by the discomfort, Ms Harris decided to visit the Accident and Emergency department at the Royal Derby Hospital, but was told the problem was likely to be a simple ear infection or mosquito bite.

It was only after she was referred to the local Ear, Nose and Throat clinic for an hour-long examination that was intended to confirm the infection, that the sickening truth of the problem became clear…the doctor said ‘You’ve got maggots in your ear’. I burst into tears instantly… I was very scared – I wondered if they were in my brain. I thought to myself ‘This could be very, very serious’”.

The doctors immediately tried to remove the maggots from Ms Harris’ ear canal, but the deeper they probed the further the maggots went inside her head, eventually disappearing from sight.

A brain scan was swiftly ordered to work out where the maggots were hiding and exactly how many of them there were, as concerns grew that or more of them could reach the brain. …The brain scan revealed the maggots burrowing inside Ms Harris’ head had left much of the area untouched, only chewing a 12mm hole in the ear canal.

Doctors decided the best course of treatment to remove the maggots was to flood the ear with olive oil.

Ms Harris said: “It was longest few hours of my life… I had to wait overnight to see if the treatment worked… I just wanted them out of me and now I knew what was causing the sensations and sounds it made it all the worse.”

Unfortunately the tactic failed, but the following day doctors were able to remove two living maggots that been flushed closer to the entrance of the ear.

Concerned that there may be another maggot they might have missed, doctors sedated Ms Harris and conducted a full re-examination of her ear. 

They were shocked to discover a further eight large larvae – what they dubbed a “writhing mass of maggots” – but with the patient sedated and the creatures easier to reach following the olive oil experiment, the doctors were able to remove them.’

With maggots getting such a hard time in the press, it is doubtless hard sometimes for those in the business to find the motivation to carry on.  It does feel like there is always going to be another story around the corner.  Despite the countless happy fish, one rogue maggot can ruin it for everyone. 

It is probably no consolation, but I think maggots are a force for good, and I hope everyone in the maggot business sticks with it and decides that, at the end of the day, despite the scaremongers, the good that the vast majority of maggots do every day all over the country make it worth carrying on.



The Health Service Journal (HSJ) has this week declared that the ‘Oxfordshire battle will determine the impact of CCGs’ (here).  This is because, as the HSJ puts it, ‘One of the largest and most advanced attempts to bring about integrated, outcomes based commissioning has been delayed following objections from two powerful provider trusts.’

So is the HSJ right? The conclusion seems to have been drawn from what the events in Oxfordshire say about relative ‘power’ of purchasers and providers.  In the private sector different industries have different relative levels of buyer or supplier power.  In some sectors buyers (like supermarkets) wield great power and can drive price down.  In others (like the oil industry) suppliers wield the power and determine the price that buyers must pay.

So the HSJ argument is constructed on the basis that the formation of CCGs was to increase buyer power over providers, and that the amount of power exerted (in this instance the imposition of a specific contract) is the marker of CCG impact.

But there is very little about CCGs that is different from predecessor commissioning organisations that would increase their ‘buyer power’.  Maybe knowledge of services by the GPs and clinicians involved in CCGs, but at best there are only changes at the margins and certainly not enough to effect a significant switch in power.

I would argue that the whole notion of relative power is unhelpful for where we are in the NHS today.  The win/lose mentality between providers and commissioners has not served the NHS well in the past, and is extremely unlikely to help in the future.  It doesn’t help supermarket suppliers or those who buy oil.  And in the highly politically charged environment of the NHS, adversarial relationships inside the NHS will always damage the consistency of public message required to enable change to happen.

CCGs are most likely to be successful not because of an increase in relative power, but because of the ability of their clinicians to create partnerships with other clinicians and drive whole system change to improve outcomes. 

It is effective partnerships that are required, not power games.  According to Wikipedia, a partnership is, ‘an arrangement in which parties agree to cooperate to advance their mutual interests’.  And while it is tough to develop strong commissioner provider partnerships in the current environment, this is what is required. 

It is tough in part because the tight financial state of the NHS means there is limited funding to smooth the transition to any new model.  It is tough in part because each organisation has its own regulator putting pressure on it to take action that may be at the expense of partners.  And it is tough in part because people are not perfect, and in a pressurized environment any misplaced comment or action can quickly undo progress that has taken months to build.

The HSJ is being deliberately provocative in stating the ‘battle of Oxfordshire will determine the impact of CCGs’, but it raises an important challenge as to how we choose to monitor their impact.  Measuring whether or not contracts are imposed is not a good marker.  Any perpetuation of the win/lose mentality of provider commissioner relationships is unhelpful.  A much better marker is the ability of CCGs to form relationships that enable new ways of working that in turn drive improvements in outcomes.  Neither CCGs nor providers can make the changes they need for a sustainable future in isolation; it has to be done in partnership.


I recently watched a TV debate about smoking and the NHS.  One man was arguing forcefully that it was his right to choose whether he smoked, how much he smoked and what he smoked, and that it was the job of the NHS to provide care for him when he needed it.  In his mind the two were in no way linked and he was irritated by the notion that the NHS might have a role in influencing his behaviour in relation to smoking.

In this country we love the NHS.  In the celebration of Britain at the Olympic opening ceremony the NHS took centre stage.  We are proud of our system because it is available to all, is free at the point of delivery, and is based on clinical need, not ability to pay.  It is our hero, because when we need it, it will do everything it can to save us.

As we consider our future vision for the NHS, the key is not so much understanding what the NHS is, but understanding our relationship with the NHS.  The man in the smoking debate was clear: the NHS for him is something akin to a ‘safety net’, there for him when he needs it.  And this is not an uncommon view.  The current furore over A&E and winter is driven largely by the symbolic importance of A&E as the front line of the safety net that the NHS provides.

Our attachment to the NHS is driven by stories of how the NHS (our hero) saved me/my grandmother/my father/my niece.  These are powerful stories from key moments in our lives.  Regardless of what happens to me or my family I know the NHS will be there for me when I need it, and that is why I will do whatever I can to protect it.  My attachment is built on this metaphor of the safety net, reinforced by powerful, personal stories.

Conversely, prevention does not create the same stories or drive the same level of attachment.  In the same way that a safety engineer that spots an irregularity in an aircraft maintenance check and prevents an accident ever occurring will never be a hero in the same way as the pilot who safely lands a misfiring plane on the Hudson river, so the flu jab will never be a hero in the same way as the hospital that nursed my grandfather back from the brink of death from flu.

And herein lies the problem.  Because our vision for the future of the NHS is one that has prevention as its hero, and that has citizens as active partners with the NHS in improving their own health.

Paul Pholeros has given a great TED talk on ‘Housing for Health’.  You can find the transcript here.  He describes how in 1985 a man called Yami Lester saw that for the aboriginal population of Central Australia 80% of the illnesses walking into clinics were infectious diseases caused by a poor living environment.  They examined the housing conditions of 50,000 Indigenous Australians and found that only 35% had a working shower, only 10% were electrically safe, and only 58% had a working toilet, all primarily due to a lack of routine maintenance.

The Housing for Health project works on toilets, showers and electrical safety, and as a result over 10 years has delivered a 40% reduction in environment related hospital admissions.  I am not doing this story justice here and I would encourage you to read it for yourselves, but the point is that providing great treatment for the infectious diseases was not the answer; rather it was preventing the diseases from occurring.

We are fortunate not to be dealing with the same developing world poverty of the Indigenous Australians in Central Australia.  But if we believe that the role of the NHS is also to improve health in partnership with the population, and not to simply provide a safety net for all, then our work on a 5 year vision for the NHS must start with this as the conversation.

Delivering 5 year plans to improve health will be impossible if we end up fighting a public whose primary goal for the NHS is to defend the safety net and the hero of curative medicine.  We need to create a new hero for the NHS, to build a belief in the power of prevention and partnership, and we need to do this by developing powerful, engaging stories like that given by Paul Pholeros as an antidote to the stories that are shaping our current thinking.


Why NHS Leaders Lack Vision

I predict that the 5 year visions that each local health economy must produce next year will in fact be far from visionary.  Great visions should be memorable, motivating and measurable, and I predict that the majority of those produced will fail all of these tests.  I am confident in my prediction because we are operating in a system that is not designed to produce great visions.

Seth Godin (in ‘The Icarus Deception’) tells the story that when a world class violinist visited the Juillard School in New York to give a speech and a performance, only 15 of the students attended.  But at the same time every practice room was booked solid.  This is because what got the students into the prestigious school was the ability to play music as it is written, to produce the notes and to follow instructions.

The dilemma these student violinists face is that what got them into the school is not going to help them when they leave.  The world is not short of good violin players.  What the world wants is original art: violin players that play music in ways that no one expects.  And this is what the young students have been culturally encouraged to avoid.

The parallel with leaders in the NHS is clear.  The Hay Group survey of the ‘top leaders’ in the NHS demonstrated that the vast majority have pacesetting as a predominant style.  Leaders in the NHS are good at getting things done.  They have become leaders because in the past when they have been asked to make things happen, they have made them happen.

But once they become a leader, following instructions is no longer sufficient.  The job now is to make the rules, not to follow them.  And we have not been trained for this.  There is no ‘what I should be doing’ because there is no ‘should’.  Now leaders must create a vision, develop the rules and make original art.

But the system of the NHS is not designed for this type of leader.  Is the NHS one organisation or multiple organisations?  Does it require one vision or hundreds?  The reforms were designed to shift the responsibility to the bottom.  To take away even the possibility of another ‘NHS Plan’.  So in the absence of a single grand plan each local health economy is asked to produce their own.

But what this means is that the NHS system as a whole should be supporting local leaders to create great visions.  In the new world, in the absence of a single plan, this has to be the priority.  But of course it isn’t.  The system is trying to find new ways to drive conformity and delivery – urgent care, finance, hospital inspections etc.  Leaders need to be immersed in the here and now.  The NHS does not want its leaders spending their time looking at other industries or other healthcare systems in other countries; what it wants is the crisis of the day to be tackled.

So with a set of leaders with no track record of producing great visions, who are busy playing the violin in the practice rooms, and with no support in place for them to produce one now, I am confident that most of the 5 year visions submitted next year will be neither memorable, motivating nor measurable.