Coda from Day One
I managed to grab a quick question with David Nicholson yesterday after his content-lite speech.

I asked him about the poor scaling and spread of good practice in the NHS, referring to Andrew Donald's recent comments that “I can get an idea taken up more quickly on the other side of the world than anywhere else in the NHS. I’m sick of going to conferences where someone explains a good scheme, and then people from elsewhere in the NHS explain why it wouldn’t work in their locality, or that they do something different which works just as well if not better … the NHS is bad at learning from itself; let alone anyone else”.
HPI: Why is this still such an issue for the NHS?

DN: "We're currently engaged in a process at the Department on what are the things we need to reinvent. There are some things we only want to do once; some we might want to do ten times ... not everything needs to be done 152 times in every PCT.

"We're going through this, and carefully deciding what needs to be done at national level.

"Another important thing in this is NHS Evidence, which is really important, so that change is all based on solid evidence".

HPI: What is the national role in practical aspects of spreading excellence?

DN: "We're looking at how to connect people in networks, possibly virtual ones, themed on geography (rural, suburban, urban) or population types.

"We're also looking with SHAs and PCTs, looking at local capacity to spread innovation, looking at the work of the NHS Institute. Jim Easton is leading on this. We won't issue 150 directives - we're looking at five or six areas".

So what else did we learn on Day Two?

The first thing I learned, reviewing my notes from Day One, was that David Nicholson did actually say something substantial - but it was in response to questions and not in his speech.

Inevitably, competition and the market raised their heads: Nicholson’s response was, “competition needs to be for a purpose people get excited about it for other reasons than its purpose. If we are told to compete for competition’s sake, tell them we won’t. Competition is the answer to not everything but it is the answer to some things”.

NHS North West head honcho Mike Farrar discussed four approached to delivering quality – the quality and outcomes framework (QOF) in the GP contract; the Care Quality Commission; the commissioning for quality and inniovation intitiative (CQUIN); and North West’s adaptation of the US Premier system in their Advancing Quality programme.

He made interesting points about the balance between more penalty-based approaches to quality (CQC and CQUIN), and bonus-based approaches (QOF and Advancing Quality), suggesting that the carrot may have more traction than the stick.

Baroness Young’s likeable presentation explained how the CQC aim to work with the RCGP’s system of practice accreditation as a semi-oproxy for CQC accreditation for general practice (the ‘Good Housekeeping mark’). Mentioning the need for attention to boundaries in care provision, the merry Baroness moved onto practice-based commissioning, observing that “I doubt how PBC fits with PCT commissioning, there seems not much in it for GPs if they lack the elbow room to redistribute spending”.

Andrew Lansley came bearing more choice; real budgets for GP practices; faith that PBC will work; reaffirmation of the independent NHS board; practices taking back responsibility for commissioning urgent and out-of-hours care; and a best-efficiency-based tariff. Oh, and when nudged by Chris Ham, Lansley stated that he wants to move to patient choice of commissioner.

Health minister Mike O’Brien’s speech largely focused on the achievements of the acute sector, which was not perhaps the best-judged.

Oh, and he mentioned that there’s going to be less money. Have you heard about that?

He also told the delegates that “reports of the death of PBC have been greatly exaggerated”. So the DH have believed that DCT was misquoted (which he wasn’t). Interesting.

He picked up and ran with Andy Burnham’s stick – the formulation about PCTs not anticipating the comprehensive spending review by initiating local cost-cutting, warning that “I will not hesitate to name and shame people who slash budgets and cut quality”. He was not forthcoming on what he would do if people slash budgets and maintain quality.

The ‘other’ category
Probably the most-cited quote of the conference was Henry Ford’s line “culture eats strategy for breakfast” (a favourite of Paul Corrigan’s). Several conversations with delegates raised the interesting tension that despite the NHS’s significantly improved average performance in key areas (waiting, HAIs, financial management) over the past decade, a ‘closed’ culture pervades that lacks the self-confidence to be open and honest (fear of a hostile media may not helop).

Chair Phil Hammond tellingly observed that a genuine cultural revolution for the NHS would be for the raising of concerns over quality and safety of services to be seen as a positive activity, rather than career-limiting disloyalty. Whistleblowers not only blow whistles, but their NHS careers as well.

Metaphors – the conference saw a lot of ‘road / journey’ metaphors. Nicholson repeated that “we’re on a journey” (it’s true, but it does make you think of ticket inspectors); Mike Dixon warned of the fork in the road, citing Bevan’s line on getting out of the middle of the road to avoid getting run down; Peter Brambleby told us that “it’s not maps that matter; it’s the journey”.

Slips of the tongue were fertile ground: Nicholson gave us the welcome concept of “beer traps” instead of bear traps. Maybe it was intended – beer traps would make us slugs? Turning to NHS cultural change, he also gave the spectacular “unless we get our minds in the wrong place, we won’t deliver”.

Dr David Jenner of NHS Alliance was on form, observing that that “everyone’s been saying PbR can’t go on, but like Celine Dion’s heart, it does”. He also gave dairy metaphors for the O’Brien and Lansley presentations – “Labour’s policy approach like an over-ripe Camembert, dripping off the plate all over the place - its smell is what made David Colin-Thomé make his remarks about PBC being a corpse) Then you’ve got emmental from Lansley – it looks glossy, but it’s full of holes”.

Former special advisers Liz Kendall, Paul Corrigan and Matthew Swindells offered interesting perspectives on their learning from policy advice to the ministers. And Muir Gray was completely wonderful.

The take-home messages? It’s up to the front line to change the culture. Competition and tendering are not always the answers (but may be sometimes). It’s also up to clinicians to get integrating care pathways across boundaries and sectors – very, very quickly. And the tariff – indeed all incentives – need careful consideration before the next operating framework is finalised.

And things need to start now. There is not much time.