In the first six months of this year I experienced CQC inspections as both the Chief Executive of an inspected Trust and as the Chair of an inspection at another Trust. I found it a fascinating experience being on both sides of the process and it prompted me, once both inspections were completed, to want to write about that experience and my views on where regulation sits in ensuring high quality health and care services.
CQC comes in from time to time for a bit of criticism. I, however, found the process of inspection on both occasions robust and fair. Post Francis it was inevitable that the regulator needed to adopt a more intensive process and I am probably, in any case, a supporter of a “boots on the ground” methodology as long as it is used proportionately. From my perspective there is much to be gained from an inspection team visiting services and meeting front line staff and service users as well as relying on external or internal data. The CQC process puts a lot of emphasis on the triangulation and corroboration of evidence to reinforce the validity of the judgements which are made. I welcomed the involvement of peer specialists and of experts by experience and the very significant added value they both brought to the inspection process. Finally the methodology rightly allows for a focus on good practice as well as the more rule bound aspects of quality.
Inspections are like visits to the dentist. Nobody enjoys them at the time but they are necessary to the health of the system. There are also clear benefits to the organisation being inspected if the process is embraced in the right way. At my own Trust the process of preparing for our CQC inspection was very powerful in helping us draw together the strands of our quality work and in ensuring good engagement with front line clinical teams on key issues. The report, both its validation of what we do well and the recommendations of where we can do better have been helpful in driving our decisions as an organisation of where we go next. I could see much the same at work in the organisation I was part of inspecting and very much welcomed the open way in which the senior team at that Trust received our findings, both good and bad.
In a system as complex as the NHS there will always be issues with any system of quality regulation. When the reputation and, at times, the future of senior individuals and organisations hangs on what is said by the regulator there will inevitably be tensions about negative judgements and ratings. CQC focuses on providers and providers may feel hard done by when the fundamental issues behind the judgements made about their performance relate to factors out of the provider’s direct control. This is particularly an issue when there is a blatant mismatch between the levels of demand providers are trying to manage and the level of investment made by commissioners. In an environment which is increasingly putting more and more emphasis on system performance it is appropriate that the focus of regulation should shift more in that direction. How to do so is still very much to be worked out.
Another unforgiving aspect of inspection is that judgements have to be made on the basis of what is seen at the time not what might be intended to happen in the future. That can be harsh on organisations where there is a genuine engagement with quality improvement but where there are major structural or cultural issues still to overcome. Whatever is said in the report a good inspection process will explain the context to judgements and recommendations and give recognition to the efforts of clinical and managerial leaders to tackle underlying issues.
From time to time there has been a debate about whether the strengthened system of inspection has been the right answer to the concerns about quality identified in reports about Mid Staffordshire and Morecambe Bay. I firmly believe that a robust system of inspection is a necessary feature of a good quality care system and that CQC’s regime, while it has room to develop and adapt, is fit for purpose. However at the same time inspection and regulation cannot be the only mechanism for ensuring and improving the quality of care.
First and foremost quality needs to be owned by the Boards and leaders of organisations. That ownership should be reflected in the amount of time devoted to quality in Board discussions and the level of inquisitiveness which Executives and Non-Executives have about what is really going on in their organisation. Wherever an organisation is in its quality journey a good inspection report should bring few surprises to the leadership of an organisation. If it does that is a judgement in itself. Boards should be prepared to invest in quality improvement. They also need to understand the implications for quality of other changes and pressures in their organisation and have an acute sense of where their “red lines” will be in terms of the risks of compromising quality.
However quality also needs to be owned by the system and not just seen as the business of providers. Improving quality is not always a question of additional investment but at a time of rising demand it is likely to have financial implications. One of the key roles of the regulator must be to provide an independent voice for quality standards with the willingness to “blow the whistle” when financial expediency potentially compromises the quality of care received by patients.
A regulator of quality is an essential component of a high quality system of care and if CQC did not exist it would have to be invented. It needs to do its job well and with integrity and now as much as ever it needs to be uncompromising in championing the voice of quality against other pressures in the system. However no one should assume that, on its own, CQC can be the guarantor of good quality care. That is all of our business.
Over the last week I have cycled some 500 miles along the line of the Western Front in the First World War. It’s been a trip I have wanted to make for some time and has been a powerful way in which to experience the landscape in which this terrible conflict was played out. In my panniers I carried, as well as maps and guidebooks, a volume of the First World War poetry as an emotional and psychological guide to what I was seeing.
Cycling is a perfect way to appreciate any landscape. You travel slowly enough to be able to observe the terrain around you and you do so with all five senses. You are acutely aware of gradient and intuitively stop at the top of any major climb to admire the views in front and behind you. You also travel fast enough to be able to see the changes in landscape and the subtle differences between areas and regions. You can travel far enough in a week to make sense of an area as large as that in which the First World War was fought.
I started in Belgium to the north of Ieper. Belgium was the little country whose fate was central to this becoming a World War. It was the official reason for Britain joining the conflict and the fate of Belgian civilians featured strongly in the recruiting propaganda of Lloyd George and other British politicians. For most of the war only a small part of the country remained in Allied hands but it was interesting to visit Belgian cemeteries and see memorials to the sacrifice made by Belgian soldiers to the war effort.
Cemeteries dominated the route. I stopped at lots and I have no idea how many I passed. There is a particular character to First World War cemeteries. They are scattered across the landscape because they reflect where men were buried at the time of battle. In many cases they stand alone at the roadside or across a field but in other cases, for instance the cemetery which I visited in Arras where the poet Edward Thomas is buried, they are surrounded by more modern buildings.
There is a powerful uniformity of design to the cemeteries: gravestones in serried ranks as if they are on parade. They are all immaculately maintained and there is an order and purpose in these places in such stark contrast to the circumstances in which many of those buried there ended their lives.
Some soldiers have names and ranks and others are anonymous, euphemistically in English “soldiers of the Great War known to God, in French much more brutally “inconnu”. Yet despite this there is an irony that the occupants of these graves are better remembered than many others who have died before or since.
The cemeteries and memorials I passed also reminded me of the range of different backgrounds, nationalities and religions of those who took part. I stopped to see the beautiful memorial to soldiers from the Indian sub-continent at Neuve Chapelle (and next to it a cemetery for Portuguese soldiers), the Irish Peace Tower at Messines (commemorating the place where Catholic and Protestant Irishmen first fought alongside each other in 1917), a memorial to Australians at Peronne, another to South African troops engaged in action at Delville Wood during the early weeks of the Battle of the Somme, a monument to the Basques and, as might be expected, memorials to Welsh troops at Langemark near Ypres and to the 38th Welsh Division at Mametz Wood on the Somme.
One of the most moving cemeteries I visited however was further south on the Chemin des Dames in the French section of the front. At Cerny en Laonnais French and German cemeteries are placed directly alongside each other. I had a sense of young men, motivated to fight each other by many of the same values of patriotism now lying at peace next to each other.
La Chemin des Dames, a long ridge north of the Aisne Valley fought fiercely over during the whole period of the War, was one of a number of places which brought home to me the importance of high ground in this conflict. My route also took me over Vimy Ridge taken the Canadians in 1917. It was staggering, as I struggled to get up them on my bike, to think of soldiers attacking these positions under heavy fire.
One of the most moving things I saw was right at the beginning of my trip. In Poperinge near Ieper (and just behind the British lines) it is possible to visit the cells in which British soldiers, convicted for desertion (some suffering from shell shock), were held the night before their execution and the yard in which they were shot. Of all the brutal images in a brutal war nothing stands out as far.
The final image of my trip is that which I have used as the header for this blog. We are used to the poppy being the symbol of the conflicts of the 20th century but it was especially moving to cycle through the battlefields and see the poppies growing amidst the cornfields, such a poignant reminder of the lives of young men sacrificed a hundred years ago.
The guns are silent and all is now quiet on the Western Front. I thought that one thing which would have united young men from all the nationalities who lost their lives on these fields was that the horrors which they experienced would represent a war to end wars. Sadly a hundred years I am not sure that we have learnt this lesson.
Andrew, ever dashing, ever bold
Will never see your friends grow old.
Your mind as sharp as all the best
Now lies, eternally, at rest.
And we will never understand
Why it was the almighty’s hand
Took you with so much more to give
Left us alone on earth to grieve.
As the summer’s heat begins to fade
All nature’s work is soon decayed.
And though our mortal frames will ail
Your memory ought not ever pale
Your smile, your wit is what we knew you by
The mystery why you had to die.
My father turned 90 yesterday. Even in an age where many more people are living so much longer it remains a very significant milestone. It felt a good time to reflect on what I most admire in him.
My father came from a very different world to the one I and my children have grown up in. Born on 2nd July 1926 in Clydach Vale in the Rhondda Valley, it was the middle of the bitter Miners’ Strike. My grandfather who had caused some sort of trouble during the strike lost his job and was unemployed until the early 1940s. As a result, like many in that community in the 1930s, my father grew up in significant material poverty. His father found solace for his disappointment in life in the pub.
Despite this my father is immensely fond of his upbringing. The Rhondda was a strong community, with an enormous sense of shared identity, based on working class solidarity, Welsh culture and Nonconformist religion. Despite individual material poverty there was a network of social support and communal facilities (including libraries and healthcare funded by the Miners’ Federation). The mountain just above where my father lived provided a wonderful playground.
My father was able enough to get to Grammar School and would have easily been bright enough to go to University. Those opportunities were not open to a working class boy at that time and it remains one of his regrets that he did not have that opportunity but one of his joys that his sons and now grandchildren have had it.
After the War, and a tour of National Service in Palestine, he did get the opportunity to go to teacher training college and spent his working life as a primary school teacher, and later head teacher, moving to Birmingham where he met my mother and where he still lives. As I discovered as a child Birmingham is, or at least was, full of Welsh teachers.
I have learnt lots of things from my father over the years but here there are the things I most admire about him and which I hope I have picked up some shadow of.
The first is his sense of community and of the equality of individuals within that community. Everybody in a community matters. Nobody is too important not to bother with other members of their community. Nobody is not important enough to be bothered with.
The second is a strong commitment to help those who are disadvantaged in society. My father’s motivation to become a teacher was an encounter with a fellow soldier when he was on National Service who was unable to read. Much of his teaching career was spent in quite deprived schools in Birmingham and in working with children who often had little motivation and encouragement to learn.
However the biggest impact on my father’s life (and indeed on my own) was the disability of my elder brother. My parents had a very difficult time when my brother was young and they were discovering the extent of his difficulties and his support (and that of my mother) for Peter has been a constant source of inspiration to me. Through my brother my father became involved in the world of disabled sport and after his retirement my father spent many years running a disabled sports club.
My father is a man of great integrity, of strong values and beliefs who is prepared when necessary to stand up for what he thinks is right. I do not always agree with him on everything but it has hard not to respect his opinions. He has always been an enemy of petty authority, most notably in a clash early in his teaching career with a martinet of a head teacher. It did not look, at the time, as if it would be a great step forward in career but it did make an impression on another young teacher at the school – my mother!
I have also admired my father’s sense of interest and enquiry. While not an intellectual or with the benefits of university education as I have had he remains fiercely interested in what is happening in the world outside. It is one of the reasons why he remains sharp and with all his faculties at the age of 90.
Finally he has been a very generous father, with his time and money. He always supported the opportunities I wanted to take as a child, even if they were not those which matched his own interests. He did so when I am sure he and my mother had to make sacrifices to do so. He has also supported my children and my brother’s children and it was lovely to see yesterday, at his birthday lunch, the deep love his grandchildren have for him.
So I have been very lucky to have such a good and inspiring father. I am very conscious of the difference such an influence can play in one’s life and the fact that many, for whatever reason, are not so lucky. So in the words of the writer of the book of Ecclesiasticus :
“Let us now praise famous men, and our fathers that begat us. The Lord hath wrought great glory by them through his great power from the beginning.”
So it won’t be long before we have driverless cars and lorries and fast food outlets are already looking to use robots to serve their food. I am sure there are benefits in both but the story of the relentless drive to replace people with machines cannot but stir some level of anxiety about the future.
The use of technology is one of mankind’s defining achievements. Whether it was the discovery of fire, the first use of stone tools, the development of agriculture, the invention of the steam engine or the internal combustion engine or the arrival of the internet and the i-phone, humans have had a brilliant capacity to harness technology to triumph over their environment and promote their species. However have we now got to the point where the process of technological development has got out of control?
There is nothing new in such fears. We are familiar with the term “luddite” with its origins in the early 19th century agitators who tried to stop the adoption of new technology in the cotton industry. The French word “saboteur” has similar origins referring to the fact that the French agitators threw their clogs “sabots” in the machinery to put it out of action.
Much of the time those who have been anxious about the advent of new technology have been proven wrong. New technology has been disruptive but in the end has increased prosperity. Old jobs have been replaced by new jobs and the world has moved on.
We have even survived 71 years in the shadow of nuclear weapons, the technology which gave humankind the potential to self-destruct. However, as the details of history become clearer, we have discovered that we came closer on occasions than we may have thought to doing so. As Barrack Obama’s speech in Hiroshima on Friday, highlights, despite a quarter of century since the end of the Cold War, the nuclear threat is far from finished.
I am not a natural Luddite although at times the passing of the “old ways” can be upsetting. I do have concerns, however, that we have lost some of the ability to harness technological innovation to address the most pressing problems faced by humankind. There are two issues. First we have allowed scientific problems, in some senses, to be prioritised over moral ones. Second, and in part as a result of the first phenomenon, we have abrogated too much of the control of technological development to private interests.
This has left us with a mixed legacy from the golden years of technological development. For instance we harnessed technology to massively drive up living standards but have been unable, or unwilling, to address the issue of inequality or even to eliminate levels of absolute poverty in certain parts of the world. Technology has not succeeded in making the world a safer or more secure place, indeed at times, has done the opposite.
There is a dimension to this healthcare. Medical research has achieved phenomenal things in the century or more in combatting disease and in extending the span of human life. For a person born in 1900 the modal age of death would have been 1, for someone born in 2010 it is estimated to be 90.
However its progress has left significant issues in its wake which we have failed to resolve and to address with the same focus as we have brought to biological medical research.
The development of medicine has n’t succeeded in reducing health inequalities and there is an increasing concern that priorities for research, in particular in pharmaceuticals, will be driven by the needs of the global elites able to pay for new treatments.
A model of medicine focused on extending life has also left a moral question about the balance between additional years and wider issues of wellbeing. I have just finished reading Atul Gawande’s excellent book “Being Mortal” which makes a very powerful case for rethinking paradigms about what matters as we grow older and frailer and what the role of medicine is in facilitating this.
So my plea is not to stop the development of technology in healthcare but rather to reframe the debate in which helps drive its priorities. Happiness, quality of life and wellbeing for the greatest number should be more central in our thinking. That would inevitably shift more focus to research in mental health, at present hopelessly underrepresented in research priorities in proportion to the size of the burden of misery and costs to individuals and society it is linked to.
In an age where there are increasing concerns about the costs of universal healthcare systems more effort should be invested into interventions which reduce rather than increase the cost of healthcare delivery, either because they can offer the genuine prospect of cure or because they can significantly reduce the costs of delivery of existing treatments. More research should go into self-care and self-management where technological enablers have some genuine potential to improve outcomes. Public health and research which focus more on the determinants of health and illness should also feature higher
All of this will require some significant changes in the setting of research priorities, systems of funding and the processes set by NICE for the adoption of technological advances and new treatments.
Technological advancement has been mankind’s defining achievement. Let it not become our master rather than servant and let’s harness it to solve those problems which are most pressing for our society.
Long before the current financial crisis hit the NHS, Derek Wanless in his ground breaking, and still highly relevant, reports on the future funding of health and social care articulated the impact of public engagement with health and treatment on the likely size of future healthcare costs. Back in 2002 he estimated that between 2002/3 and 2022/3 the gap between a “fully engaged “and a “slow uptake” scenario for the development of the NHS would amount to £30 billion or 16% difference in the funding requirements for the formal system of care. Even in times of relative plenty Wanless argued that a very different approach to delivering health care was essential if we were continue to be able to afford a high quality health service in this country. How much more so in times of austerity when it appears unlikely that we can afford even the most optimistic requirements which Wanless put forward for future funding.
At the heart of public engagement must be a genuine commitment to empower the public to look after their own health and to treat those who become “patients” in the formal care system as genuine partners in and co-producers of their care. In doing so we should aim at a goal of increasing “health literacy” so as to enhance the knowledge and motivation which people have to look after their own health and to maximise the benefits of any treatment they receive.
Just before Easter I was lucky to join a conference organised by Oxford University’s Health Experience Institute considering health literacy. It made me think hard again about this question which has been relevant to many of things I have done in my career, most notably in the time I spent at NHS Direct. It should be an issue at the very top of debate about health policy making and delivery but in reality, but despite lots of small scale good practice, it has received spasmodic attention and follow through.
There are lots of reasons why this is the case but the most fundamental one, I believe, is a question of structure and beliefs. We call our system the National Health Service but we organise and deliver it as the National Illness Service. We can talk about self-care but we rarely organise ourselves to support it in any meaningful manner.
If we are to take the issue of health literacy seriously I think there are a number of things we need to do.
First we need to reprioritise spending on public health and self-care. I for one supported the idea of separating public health from the NHS, integrating it in local Government with control of some of the wider determinants of health and making a long term commitment to improving health and health literacy which was separate from the arguments about NHS funding. It has been sad to see this vision undermined by the level of reductions in public health budgets which I fear will have long term consequences for health outcomes and increased pressure on the NHS.
There is also an argument for investment in the very best of health information and advice, recognising that self-care and self-management need to be supported. Yet, despite the rhetoric, it is always these resources which are the first to be cut when budgets are squeezed. NHS Direct was much more than a means of managing demand for urgent care and represented a world class resource for supporting self-care. It was a retrograde step when it was closed.
Second we need to move away from the puritan and judgemental rhetoric which has characterised too much of our health promotion activity and shift to a greater focus on individual wellbeing and motivation. Individuals rarely see health as an abstract concept unconnected with the wider circumstances of their lives. As we know very clearly in mental health, jobs, housing and relationships matter as much as do formal health care interventions in improving health and wellbeing. The crucial ingredient in successful health promotion is individual agency. If we just lecture people about their lifestyles we will be doomed to failure. However if we work with people in ways which build trust and tap into their own motivations to change then we have a chance. From my experience I believe that voluntary sector and peer organisations, with their traditions around more holistic and creative models of working, have much to offer. I loved hearing about the dance class at risk for older people which aims both to boost wellbeing and reduce the risk of falls.
The third thing is to restructure professional education to put a much greater emphasis on the skills and shared decision making and co-production. There is clear evidence that shared decision making can improve concordance with treatment (it remains staggering that between 30-50% of prescribed medicines are not taken), improve health outcomes and many cases can lead to the choice of less expensive interventions. The skills of shared decision making are not necessarily the traditional skills of clinical consultation. It has been exciting working with the Dartmouth Center for Health Care Delivery Science on the use of measurement and delivery tools to support shared decision making in CAMHS services. Amongst other things, Dartmouth’s evidence suggests a marked difference between the views of patients in whether they have been involved in decisions about their care from those of the clinicians treating them.
The final thing is to think through how we structure the delivery of care in ways which put patients and not the system at the centre. The ever increasingly transactional nature of services and greater fragmentation of care works against this. We need, alongside patients and families, to think through pathways and to understand how we can support patient engagement and health literacy at each stage, not just in the consulting room, but through all of our interactions and communications. A key point would be the effort, both practical and psychological, we invest at the point of diagnosis. Given that long term conditions will be at the centre of the demand for healthcare this could be time well spent if our objective is to help patients manage with confidence and skill their own conditions and reduce demand on formal services.
This is an urgent agenda. We are a long away from Derek Wanless’ “full engaged” scenario and the gap between what we need to be and where we are is getting wider. This theme is not lacking from the Five Year Forward View but needs rapidly to come much closer to the fore. If it does n’t our chances, as his report 14 years ago highlighted, of delivering a sustainable NHS will be that much harder.
It’s one of those paradigms that age brings wisdom but is it always true?
Since I turned 50 a couple of years back I’ve reflected a lot on what it means to grow older. I have also reflected on what the value is of that half a century of experience.
Experience very clearly does bring benefits in both my professional and personal life. First, and quite straightforwardly, I know a lot more than when I was young. That gives me a competence in doing things which I might have previously struggled with but just as importantly it lowers the anxiety of handling a wide range of situations. I am more confident in dealing with people, in meeting deadline and in solving problems. Experience and practice has helped me refine the psychological skills of managing these situations and has helped me to calibrate my understanding of situations and to distinguish those which are routine and those which are particularly challenging. Such experience doesn’t always make me wiser or better at doing things but it helps.
Experience also makes me better at understanding the context of situations. There are many more things I have experienced myself or seen other people experience or read about other people experiencing than when I was 20. As a historian I put a lot of emphasis on the repeating patterns of human history. Our own age, with its globalised networks, instant communications and rapidly evolving technology, can appear distinctive but it is not unique. There are historical precedents to the challenges we face today and while history and experience do not necessarily provide the answers to contemporary problems they do help in asking the right questions. They also provide salutary warnings about the perennial nature of human folly but also about our resilience and adaptability. At times there is a danger that such experience can make one overly cynical but, in general, it is a salutary feeling.
Age has also made me more of sure my loves in life. Youthful enthusiasms can be powerful but they are not the same as the affections which come with experience. Whether it is the music of Beethoven and Bach, the novels of Trollope, the sight of the hills or the sea, the poetry of Shakespeare and Homer or a Welsh victory against the old enemy there is something deeper in my sense of satisfaction in the things which I have grown to love over a lifetime. For a long time I would avoiding rereading anything I had read before on the basis that it might distract me from new discoveries. Nowadays there is a special pleasure in returning to books or poetry I have read before knowing that they will yield up a new level of pleasure not because they have changed but because I have. The eyes of an older person see things invisible to their younger self.
The same is true in relationships. However important their roles were in my first decades of life I have got to know my parents and my siblings much better as an adult. My relationship with my children is richer and closer in many ways now they have grown up and are beginning to make their own way in the world. The same is true is the closest and most important relationship of my life. Falling in love is a fantastic and intoxicating experience but it does not beat the more profound joy which comes from having shared 26 years or more of life together.
So age brings many consolations but it also brings challenges and previous experience is not necessarily a guarantor of wisdom in dealing with these. Foremost of these challenges is that of accepting loss.
First there can be the loss of health. Here I have been very lucky and many ways feel as fit and healthy as 53 year old as I did at 20 but I can begin to see the first signs of decline, some loss of my hearing, the increasing incidence of frustrating moments when my memory fails in ways it would have never have done in the past. It has been sad to see others, my parents included, struggling with poorer health and diminished physical and mental capability. Adjustment to weakness and frailty is never easy.
Second there is the question of when to give up activities which one no longer has the capability, in its fullest sense to undertake. For my generation work will no longer be bounded by established norms for retirement set by the state and economic realities will keep many working who might have previously looked to retire. Work can be good for many older people in keeping them active and engaged with society and their experience, for all the reasons I have described above, is to be valued. There is a time, though, when it is right to finish and to do so with grace.
Most importantly in growing older there is the need to reconcile oneself to the ultimate loss. Mortality is a condition we all share. It can be postponed but never avoided. The greatest wisdom is how we can adapt ourselves to accepting that inevitable fate. For once I do not agree with Dylan Thomas: we should go gently into that good night.
In all things the most important knowledge in growing older is the knowledge of ourselves. Without that our greater experience of life can become meaningless, making us prone to making the same mistakes we have always made and leaving us unprepared to deal with the ultimate challenges of life.
Older and wiser? We’ll have to see.