How do you solve a problem like primary care?

I recently had the unpleasant experience of developing an eye infection – acute conjunctivitis.  However, before I had been diagnosed, my immediate reaction wasn’t to go to the GP or A&E (although at 3am in some amount of pain the thought did cross my mind) but to go to the community pharmacist who did a great job of diagnosing and prescribing me the right medication in less than 5 minutes.  This experience got me thinking about the current pressure on primary care and how to resolve it.

In November 2013, the Royal College of General Practitioners (RCGP) and the National Association for Patient Participation (NAPP) launched a campaign called Put Patients First, Back General Practice.  This campaign has called for the funding for General Practice to be increased from the current 8.5% to 11% by 2017.  A big challenge in the current financial climate.

There are increasing demands on general practice which NHS England produced an evidence pack to support in August 2013 called Improving General Practice – a call to action.  In this pack they estimate that for the roughly £8billion of funding there could be as many as 340 million consultations per year with a funding allocation per head in England of £143.61 (http://www.england.nhs.uk/ourwork/qual-clin-lead/calltoaction/igp-cta/). 

In this pack NHS England describe one of the biggest pressures on General Practice as being rising patient expectations.  It seems to me that the old wisdoms that you can’t treat the common cold with antibiotics and you need to rest a strained muscle for up to 6 weeks so it can heal appear to have been forgotten.  Patients don’t seem to be happy with the GP appointment unless they leave brandishing a prescription or a referral.  The commitment that you can see your GP within 48 hours or be seen in A&E within 4 hours are becoming increasingly difficult to meet and so patients are feeling frustrated and more people are going to A&E as they can’t get into see their GP.

My recent trip to the community pharmacy got me thinking about potential solutions.  A large proportion of people go to their GP for a repeat prescription or for minor ailments.  These patients would be better off going to a community pharmacy in the first instance.  Many pharmacies have consultation rooms, which are often underutilised.  There could be community nurses or practice nurses available to check people’s blood pressure etc as they do in the GP practice, so that they can safely have their repeat prescription.

According to Pharmacy Voice 1.6million people go to a community pharmacy every day, whether to pick up a prescription or buy shampoo.  This has huge potential to educate the public as to how to best use their pharmacy and GPs should also spend time promoting their use. 

Pharmacists spend four to five years training and have a wealth of knowledge and experience regarding medication, often more than the prescribing doctor.  This feels to be to be an untapped resource that could really benefit from being promoted and is there already so could have a more immediate impact on taking the pressure off general practice.

The financial pressure that the NHS is experiencing mean that in order to increase general practice funding by £3billion this money will need to be taken from somewhere else, which in the current climate is very difficult.  However, we could make better use of their current funding levels by making sure that we use our general practice resource in the best way possible.  The extended use of community pharmacies is a good way to ensure that routine patients continue to get the care they need quickly, easily and locally whilst supporting general practice to see the more complex patients.



Do we need Superman to rescue us from our burning platform?

There has been some debate recently about the role of the ‘Superhead’ in education and whether or not it would work in healthcare.  The theory being that we could have SuperCEOs that will start to manage the struggling providers and pull them round to being successful organisations. 

Good theory.

What about the reality?

I’m not sure that this works as healthcare is a very complex system and organisations are struggling for a variety of reasons, not necessarily just due to the leadership.  Heroic leadership is a dangerous principle particularly when the average tenure of an NHS CEO is 700 days!

Seven hundred fantastic days with the SuperCEO at the helm and then the slow demise of the organisation, this doesn’t sound like the right answer to me. 

Organisations need leaders at all levels.  Distributed leadership drives innovation and change.  We need to not only engage with staff but also empower them to be part of the solution.  Leaders are found at all different levels and in all different professions and often in the most unexpected of places.  The truly heroic leader is the one who seeks this out, identifies the individuals and supports them to make the change the individual themselves wants to see.

The professional stand off between clinicians and managers still appears to exist in pockets of the NHS but it has had its’ day.  Collaboration and distributed leadership need to be the vanguard of the New NHS.  The CQC well-led domain is starting to be able to correlate a direct relationship between the relationship between the managers and consultants and the quality of patient care.

This feels to me as though the staff within those organisations have lost sight of what is important and why we go to work every day – the patient.  Without them, there would be no NHS.

Distributed leadership allows clinicians, admin staff, therapists, managers at all levels contribute to the organisation and ultimately the patient experience.

The age old adage of together we stand, divided we fall, has never been so true.

The NHS is facing extreme financial pressure in 2015/16 and this is a burning platform that the combined efforts of the 1.3million staff within the NHS need to pull together to work through, rather than pulling the NHS apart.

I am a great believer in people and feel the NHS is made up of a huge amount of talented and dedicated people.  We just need to find a way to unlock that talent and creativity towards the greater good of the NHS and not wait for SuperCEO to put his/her pants on the outside of their trousers and come to our rescue.


Does money really make the world go around or are we motivated in a different way?

It is a hugely challenging time for the NHS.  The funding gap is estimated to be £2bn and with pay making up 70% of the costs in the NHS, substantially increasingly salaries in order to incentivise staff is not a viable option.   So how do we motivate staff to release that discretionary effort that we need to improve patient care without financial incentives and rewards?

But for to those that work in the NHS is it really about the money?

In 1964 Hertzberg revealed his motivation and hygiene theory, he hypothesed that money was hygiene factor i.e. people need to be paid a fair wage for the job they do and they appreciate a pay rise or a bonus but it doesn’t last.  It isn’t a motivator.  Fast forward to 2005 and research conducted for the Federal Research Bank of Boston by Dan Ariely et al from MIT demonstrated that financially linked reward actually reduced performance, which is completely counter intuitive https://www.bostonfed.org/economic/wp/wp2005/wp0511.pdf.  So if money doesn’t motivate or improve performance then this could actually be good news for the NHS but how is it achievable?

Daniel Pink, Al Gore’s ex speech writer, has written a fantastic book called Drive (2009), which is definitely worth a read, as he describes how to release the intrinsic motivation within people.  He cites three factors:

  • Autonomy – control over your own destiny, how you work and the ability to make decisions
  • Mastery – the ability to become extremely proficient at something
  • Purpose – doing something you believe in, that drives you and speaks to your values

People work in the public sector, and particularly the NHS, for a variety of reasons, however the majority of staff really believe in the NHS, its core values and what it achieves.  They feel their purpose links to the wider purpose of the NHS and they have the potential to love what they do.

Healthcare is a complex field and therefore it has very bright and very skilled people who work in it making life and death decisions to help millions of people every day.  It is also a fast moving sector as technological advancements mean that the clinicians and managers are constantly changing and adapting how they work.  Mastery and being an excellent clinician or manager in this complex environment brings with it a huge sense of pride and supporting staff within the NHS to be the best they can be will improve patient care and outcomes beyond compare.

Being valued and trusted as an employee demonstrated by having control over your own work environment and autonomy cannot be underestimated.  The predominant ‘pace setting’ leadership style (Goleman 2000) that has dominated the NHS over the last ten years as a by-product of the target culture, has meant that the autonomy of many staff has been challenged and a learned helpless prevails.

It seems to me that we may be missing a huge opportunity and one that would really benefit the NHS as a whole by considering how we support staff to develop autonomy, mastery and purpose. We need to help staff to unleash their intrinsic motivation so that they feel empowered in their day to day work and as a direct result improve patient care.

For Daniel Pink’s TED talk http://www.ted.com/talks/dan_pink_on_motivation#t-589324