Two questions for the Shelford Group

Lots of us have issues with elitist groupings.  There have lots of issues going against them - primary among these is the fact that they are elitist.

For example, take the G-14 grouping of the top European football clubs such as Paris St Germain, and Bayern Munich (this grouping existed between 2000 and 2008).  They used to boast things like that they had won the Champions League 41 out of 51 times; 2004 was the first year that a G-14 member was not in the final; between them they had won the league title 250 times . . .

Lots of us have lots of issues with these sort of things.  First, not many of us are surprised that if you form a grouping of the most successful teams, then those successful teams are by definition going to have won a lot.  It is not rocket science.  Secondly, not many of us appreciate smug people who revel in their self-importance, and do not look closely at the what caused their important.

Now, let us look at the Shelford Group - the group of 10 self-aggrandising NHS Trusts  - all with academic links, all with tertiary services, all with self-importance.  This is what they say about themselves on their website: "The Shelford Group comprises ten leading NHS multi-specialty academic healthcare organisations. We are dedicated to excellence in clinical research, education and patient care. We aspire to demonstrate system-wide leadership for the benefit of patients and the prosperity of our country."

My response is "Yes" in the literal sense.  And "So What" in the emotional sense.  Yes, you may think that - but who does not.  Which Trust is not dedicated to clinical research or education or (surprise here) patient care? Who does not aspire to that gibberish.  The very fact that a PR person could write that down without getting you to challenge your own beliefs and strategies shows how vacuous it is.  Which then results in "So What?"

Given the Shelford Group does not mean anything; can I come down to the 2 most important questions I have for them:

1.  What are you going to call the grouping now? Now that Gareth Goodier has moved from Shelford (where he used to live) to Melbourne (allegedly Ringwood), the reason for calling it the Shelford Group is no more.  I am happy to take suggestions in the comments section.

2.  Do the chief executives within the group without a knighthood/ damehood get looked down up? Tim Smart, Bill Shields, Mike Deegan and Keith McNeill may be able to tell us.  Again - Tim, Bill, Mike and Keith - via the comments section, please.

Now, for let me rearrange the monthly performance reports or perform some other equally pointless task.

South! What KHP has to do with Polar Travel

I know friends and colleagues at the foremost Academic Health Science Centre south of the Thames, but north of the Surrey Downs, east of the M3 but not as far as the sea: King’s Health Partners, often wonder and worry about what their CAGs (Clinical Academic Groups) are.  CAGs say the KHP authorities are how the AHSC is going to be organised around clinical areas.

But the real people on the ground, and not the people who are paid to pontificate, wonder about these strange things called CAGs.  What is their purpose?  How long do they last for?  And is there an end in sight?

Militant Manager can offer them some solace, and explanation.  MM was able to understand what a CAG was not by reading the KHP website; but by reading about the Scott Polar Expedition of 1910-13.  It was in the book by Apsley Cherry-Garrard titled “The Worst Journey in the World” that MM came across what constituted a CAG.

The definition can be gleaned from the following paragraph, taken from page 194 on “The First Winter.”  This was a narrative of what the first winter in the freezing cold (Cancer CAG can understand this) was like.

“One great danger threatened all our meals in this hut, namely that of a Cag.  A Cag is an argument, sometimes well informed and always heated, upon any subject under the sun or temporarily in our case, the moon.  They ranged from the Pole to the Equator, from the Barrier to Portsmouth Hard and Plymouth Hoe.  They began on the smallest of excuses, they continued through the widest field, they never ended; they were left in mid air, perhaps to be caught again and twisted and tortured months after.”

I know colleagues at King’s Health Partners can well sympathise with this definition of a CAG.  It is certainly more representative of the Dental CAG than the official description.  Who in the CardioVascular CAG will not argue that they are only sometimes well informed.

And it was all foretold almost 90 years ago.

KHP colleagues will also understand why the book is called “The Worst Journey in the World” and why despite heroic leadership, and superhuman effort, the Polar Party all perished.  I hope that the perishing in KHP’s case is purely metaphorical.

Most popular Militant Manager posts in 2011

These were the most read stories in 2011, with the number of unique people reading them during that year.  Please note that the number of unique readings are an underestimate of true readers (the majority of viewers go directly to the main Militant Manager blog page - militantmanager.blogspot.com - and cannot be attributed to any one article without detailed analysis.  And as we know NHS Managers are not capable of doing any analysis).


1.  Noble resignation or convenient excuse to focus on greener pastures 279 views
This readership is surprisingly large given the article was only posted on 13 December, and so only had 3 weeks in 2011.


2. Why consultants need more natural predators 270 views
Another post that focused mainly on issues related to doctors.  Interestingly, when I started the blog, my view was that it would be more read by managers.  But it seems that the blog is far more read by doctors . . .


3.  More Del boys will become GPs  124 views
Another issue focused on doctors, and looking at the subtle effect of the health reforms on the composition of GPs.  I must point out that I neither support nor condemn these effects - I am just pointing them out.


4.  The similarities between car design and NHS structures  111 views
The most popular article focused on management issues.  I thought this article deserved greater readership, but it was not to be.  Maybe it will develop a cult following.


5.  The point of Academic Health Science Centres 97 views
On the whole, my more tongue-in-cheek articles (on Clare Gerada, on Bruce Keogh, on Cynthia Bower, David Nicholson, and Richard Smith) did not rouse great interest.  This was the exception.  Probably because Academic Health Science Centres, like Secure Facilities, do not have a point.

Just why is this man the NHS Chief Executive?

Can somebody explain how a man with such little vision and ability as David Nicholson is the NHS' Chief Executive?

Let me give you two recent examples:

• His review of Innovation.  This has produced the proposal that Trusts should comply with national procurement guidance or explain ("comply or explain").  Am I mad, or is this the antithesis of innovation?  Perhaps the official language of the NHS has been changed to newsspeak. 
  
  Perhaps he would like to explain NPfIT, PFIs and other centralised procurement schemes, before he opines on the merits of centralised bureaucracies.  Talking about taking accountability for decisions, when is he going to take responsibility for the mega-folly that was NPfIT for which he was SRO?  Perhaps he can do that before he begins to lecture others.
  
  Nicholson went onto indicate that in principle Foundation Trusts should be brought to follow the same rule, but “Organisational independence [currently] seems to trump value in a big way.”  Isn't that the point of a FT - that it is not run by a bureaucrat based at Richmond House?  More on that below.
• His separation from reality.  In another recent intervention (at the Mid-Staffs inquiry), he proposed that DoH should retain the possibility of de-authorising FTs.  This is contrary to the general shift of policy for 25 years; and is his job not to implement an elected government's policy?  And what is the benefit of de-authorisation?  That it comes under SHA control?  So let us take London: perhaps he can explain to us why SHA control of BHR, Whipps, West Middx, St George's, South London, St Helier and Newham has produced such great results.  Beyond going against government policy, what is his evidence?

All I can conclude is that this man is a bureaucrat with no driving vision; or that his priorities are on other things if he cannot find a coherent vision for how the NHS should function.

The point of Academic Health Science Centres

I have finally figured out the point of Academic Health Science Centres.  It is to create more jobs for the boys (and, more rarely, girls).

As I have commented before, the NHS goes through cycles of structural change.  During these structural changes the top jobs tend to vary according to the point in the cycle.  In the current point, where organisations are being merged, senior jobs clearly drop.

So what does a bureaucracy do when its jobs are threatened?  Find alternative locations to house its own.  And these are the Academic Health Science Centres.

As we know these AHSCs do very little, but they all seem to have a full board and senior leadership team.  For instance, Cambridge has 4 executive, and 12 non-executive members.  Manchester has a lot too - though it is a bit confusing as to what they do.

Now, once you have a board who does very little, and has done very little, what is the next step?  Order a review to help understand what you should do with this pretty organisation which does jack.  And all the better if the review is done by another member of the great and the good, with consulting support by articulate, intelligent, dim-wits.  So Imperial has appointed Ara Darzi; and King's - William McKee; UCL has appointed Edward Lavelle

Militant Manager's view is that if after so little time of such a heralded process, you have to do a review about where to go, the whole enterprise is of questionable value.

But I am not sure about that; I wonder if Lord Turner is available to do a review of that conclusion?

Does competition improve quality in the NHS?

A debate has recently been re-ignited by Zack Cooper and colleagues' article in The Economic Journal on whether hospital competition improves clinical quality.  Cooper et al find that "hospital competition can lead to improvements in hospital quality."

Such a finding immediately attracts attention.  If true it would vindicate the policy of choice and competition, and as such receives warm welcome in some areas.  In others, it is lambasted.  For example, Allyson Pollock, professor of public health research and policy at Queen Mary, University of London, claims many faults in the research.

As an aside, Militant Manager cannot understand how Ms Pollock is a professor of anything.  There is no disinterested detachment that you would expect from an academic: her website, her writings and her approach are all about confirming her beliefs, rather than challenging them in the face of evidence.  The references she gives for her claims (on the lack of link between competition and quality, and on the limitations of data and methodology) are so generic, it begs whether she has really gripped the detail.

Back on topic, MM also has some qualifications on Cooper et al's findings.  MM did not have access to their latest peer-reviewed publication; and so had to do with reading their working paper.  They essentially find that hospitals who in more competitive markets have better mortality figures for heart-attack emergencies.  MM's issue is whether this may be because more local hospitals allows the ambulance to route heart attacks to the better heart-attack centre (as happens in London?).  So this finding would not be because there is competition, but because there are a number of local hospitals, and ambulances are routed.  Perhaps Cooper et al may have addressed this in the EJ article; but MM would appreciate a better understanding of this.

Nevertheless, what MM found convincing was Cooper et al's review of the literature on the impact of competition on quality in the US (section 3.1).  What they document is a number of consistent studies that show that in a regime of fixed prices, increased competition results in increased quality.  This is exactly the situation in the NHS.

That is the most powerful finding for MM; and one that many should pay attention to in designing or criticising reforms.

Why NHS Direct is sitting on one nail

Militant Manager is always puzzled by some things in the National Health Service.  Why do GPs vote for less private sector involvement when they are private contractors themselves?  Why do NHS Trusts work so hard to abide by the EU Working Time Directive, yet allow their consultants to moonlight in the private sector without any restriction on working hours?  Why are there so many bodies who bring out (at times conflicting, and contradictory) guidelines, and rules?  Why would a Secretary of State believe that the optimal method of arriving at the best size of commissioning bodies is by imposing arbitrary management cost allowances?  How can those organisations that rely on concentrated, block contracts ever be judged suitably independent to satisfy the requirements of Foundation Trust status?

It is this last question that I wish to address today.  And it brought into stark relief by NHS Direct which has announced its intention to seek FT status.

Militant Manager knows buy-out and venture capital types (some of them have washed up in Monitor).  Buy-out and venture capital types are good for three things: one is running a good LBO model on Excel (which is not very useful in any other walk of life); two is sitting on boards looking empathetic, but continuously wondering how they are going to explain this to their limited partners and colleagues; and the third is to glean a vague sense of what factors could bring a company down suddenly.

And it is this last thing that is useful in this instance.  One of the things that gets them more excited than a good LBO model, and a board meeting going off plan, is a business with a concentrated customer base.  They know that this will make independence and sustainability difficult.  And given these private equity types have only three useful things to say to the world, we should pay attention to at least one of them.

A business that depends on a very concentrated customer base - and in NHS Direct's case, almost entirely on one customer - is not a business (let alone a self-sustaining one).  It is a hobby like a vintage motorbicycle - entertaining for the owner/ client, but first to be jettisoned in harder times.  Or it is a project - like measuring lichen on Derbyshire hills to understand whether they grow in the sun or shade; whether they grow near roads or near forests.  At the very best, it is an outsourced contract from that key client.  It is most certainly not a client.

The sharper amongst you will be wondering why this does not apply to other project companies like Serco or Capita.  But there is a difference.  Serco and Capita have a large number of contracts; which are not co-terminous and are spread across sectors, clients and geographies.  It is a bit like nails.  If you sit on one nail, it is quite painful and lethal.  But if you sit on a thousand nails, then it is uncomfortable, but not lethal.  Nick Chapman is sitting on one nail.  Tom Riall is sitting on a 1,000.  Whose arse would you rather be?

The even more sharper amongst you will now be wondering why this argument does not apply to Mental Health Trusts, and/ or Community Trusts.  And MM would argue that it does.  But it is a question of degree and judgement.  The four axes to judge on are:

1. The concentration of payors, and their correlation with each other.  NHS Direct has one customer now, but even when 111 is implemented and it gets 10 customers, the customers will be looking to it for the same niche. A niche borne of national initiative.  So if one cancels a contract, it is likely to be because of a change in policy which is replicated elsewhere - so the customers decisions in this regard are very correlated.
2. The avoidability of the fundamental need.  Schizophrenia is not going to go away.  But the need for 111 may well do so.  So Mental Health Trusts are more sustainable than NHS Direct.
3. The distribution of decision making.  Mental Health Trusts get referrals from 100-200 GPs from each PCT - which evidences distributed decision making.  And the PCT commissioning decision is borne of a long history with a number of related parties involved, including social services, police and PCTs.  NHS Direct gets commissioned by some pointy-headed person in the East of England.
4. The independence of price.  In acute care, PbR and tariff are not set by customer and provider.  They are set independently of both, and are a "datum".  This enhances independence.

So when judging the sustainability of organisations, one has to look at these four axes.  So what do I conclude from this:

• NHS Direct is at the extreme of suitability for FT status, and is basically not suitable. Hopefully somebody will listen to me this time.  Not like last time, when nobody listened to me when I said that Europe was not a sustainable single currency area.
• Many Mental Health Trusts and Community Trusts also fail this fundamental test.   Forget about Ambulance Trusts.
• Monitor should start to realise this.  At the moment, Monitor just judges whether the organisation is well controlled and managed at the time of authorisation - but it is possible to manage a hobby or a project well.  The question is whether it is sustainable, and Monitor's assessment (like investment bank risk models in 2007) does not really take into account the full range of eventualities.
• With the concentration of commissioning, acute Trusts are also becoming less sustainable.

The truth, however, is that it is hard for all parties to consider this reality.  They would rather whistle while they sit on a nail.

The similarities between car design and NHS structures

Car companies have a sophisticated strategy for their cars over time.  Their initial authority is over a particular segment.  But over time, they want to play in different segments.  And they do this by slowly invading that space with a model that consumers are familiar with, and taking their authority and consumers with them.  At the same time, they introduce a different model to fill a space customers already trust the marque with.

This can be seen clearly with Volkswagen's hatchback strategy.  So today's Volkswagen Golf (which is in its 6th iteration, i.e. Mk6) is 50% larger than the original Golf Mk1 introduced in 1975.  It is in effect an offering for an entirely different customer segment.

But on average cars do not get bigger.  And that is because as one model migrates away from its entry configuration, the marque introduces a new model to fill the space it leaves behind.  In Volkswagen's case, as its first family hatchback (the Golf) grew in size, it first introduced the Polo and, as that also grew in parallel with the Golf, it introduced the Lupo/ Fox.

The size changes of Volkswagen's hatchbacks since 1975 can be seen in the chart below.  Size in this instance is calculated as the floor area of the car (length x width) in square metres.

Plus ca change, plus c'est la meme chose.  Even though each model gets bigger, the overall market still looks similar.  So you can see that Volkswagen had an offering in the size range of 5.5 to 6.0 sqm from 1975 to today.  And ever since the early 1980s, it has had a model in the size range of 6.0 to 7.0 sqm.  So though things look like they are changing, they are not.  My child has illustrated this paradox with a drawing of her own.  It is meant to show that each column and each row has a car of each size (small, medium and large) even though it all looks different (at least that is what it is meant to show; please cut her some slack, she is only in the 4-6 bracket).

What does this have to do with the NHS.  The similarities are uncanny.  The thing that changes here are the commissioning bodies.  As a proxy for size, Militant Manager has used the number of bodies that cover England.  So if 5 bodies of a certain level cover England, they would cover a much larger population each than if 50 bodies did the same job.

The similarities between the NHS and car design can be shown by the size changes of NHS commissioning bodies since 1990 - as illustrated in the chart below.

This shows that new bodies are introduced at a small size; and over time they grow in size with each restructure.  Over time bodies grow and die; but new ones are introduced.  So 500 PCGs have now made way for 50 PCT Clusters; 100+ Health Authorities will make way for 4 SHA Clusters by 2012.

It's deja vu all over again.  Despite these changes, nothing really changes.  So as you can see there has always been a body at the 300-500 size level since 1997.  And there has also been a regional structure between the Department of Health and this 300-500 level. 

These are incontrovertible facts; but each generation of politicians and officials think they can do something new.  And like those amongst our organisations who feel there is a technical fix to everything; there are those that think there are structural fixes to everything.

I fear that this may all be caused by the management consultants.  Who has not heard of the consultancy who gets called into a decentralised firm, and insists it should be centralised; and goes into a centralised firm, and calls for decentralisation?  This also sounds like the product of a series of structural reviews by consultants - who understand the problems with current situations; but cannot optimise overall; and cannot place their solutions in greater historic context.

But there isn't a structural fix for everything.  Somebody has already thought of it 20 years ago; and we are all tired of structural fixes.  After a series of these changes, we are exactly where we started.  And a lot of effort, time and money has gone into navel gazing.  The NHS structure is not a consumer problem like car design.

So what are the other lessons for the NHS:

1.  NHS structures change too quickly.  If car companies take 6-7 years to introduce a new model because it takes that long for consumers to adapt and factories to settle down and then be retooled; why would you think that organisational structures (which require much greater familiarity and comfort) can be turned on its head every 3-5 years (as seems to be the current average in the NHS).

2.  The NHS introduces too many names.  After any restructure, there is no need to call it different.  So District Health Authorities need not have been called Health Authorities and then Strategic Health Authorities.  The NHS could have built 20 years of brand equity in the simple, all-season name of "Health Authority."  In fact, while we are on the topic of ridiculous arguments, the NHS' names are too boring.  Why cannot SHAs be called the "Kalahari" or "Focus."  We should be more imaginative.

3.  There is no beauty in symmetry.  So though Volkswagen cover the small family segment via three equally spaced hatchbacks, other marques do it differently.  And there is no "Department for Cars" that mandates a symmetrical approach in every company.  Similarly, the NHS should be able to develop its structures differently in different areas.