Module 1 - New Models of Care

Hello and welcome to the first KSS Darzi Spark Report!

Coming to you from across Kent, Surrey and Sussex, this represents a collaboration and gives you a taste of what Darzi fellows learn about when on study days at the London South Bank University.

We spent most of the three days within one large room. To begin with, we sat in the large circle and introduced ourselves. We shared details about who we were, what our jobs were and anything else we felt the group should be aware of.

We moved from small to large groups and back again throughout the day. Over time we observed how the layout affected how we interacted, both with ourselves and the invited speakers.

Value was gained from both small and large groups, and it was interesting to compare this to our subject at times - localism, devolution, centralisation.

Who is responsible for the death of the Baroness?

In our small groups, we were asked to listen to the following story and, from a modern perspective, rank the characters in order of their responsibility.

"As he left for a visit to his outlying districts, the jealous Baron warned his pretty wife: “Do not leave the castle while I am gone, or I will punish you severely when I return.”

But as the hours passed, the young Baroness grew lonely, and despite her husband’s warning, decided to visit her lover who lived in the countryside nearby.

The castle was located on an island in a wide, fast flowing river, with a drawbridge linking the island and the narrowest point in the river.

“Surely my husband will not return before dawn,” she thought, and ordered her servants to lower the drawbridge and leave it down until she returned.

After spending several pleasant hours with her lover, the Baroness returned to the drawbridge, only to find it blocked by a guard wildly waving a long and cruel knife.

“Do not attempt to cross this bridge, Baroness, or I will kill you.” he raved. Fearing for her life, the Baroness returned to her lover and asked him to help.

“Our relationship is only a romantic one,” he said, “I will not help.” The Baroness then sought out a boatman on the river, explained her plight to him, and asked him to take her across the river in his boat.

“I will do it, but only if you can pay me fee of five Marks.”

“But I have no money with me!” the Baroness protested.

“That is too bad. No money, no ride.” the boatman said flatly.

Her fear growing, the Baroness ran crying to the home of a friend, and after again explaining the situation, begged for enough money to pay the boatman his fee.

“If you had not disobeyed your husband, this would not have happened,” the friend said. “I will give you no money.”

With dawn approaching and her last resource exhausted, the Baroness returned to the bridge in desperation, attempted to cross to the castle, and was slain by the guard.

Our instructions: "list the players in this tale in order of most to least culpable.."

  • The Baron? "he gave the order"
  • The Baroness? "she should have obeyed"
  • The Guard? "just doing my job"
  • The Boatman? "just doing my job"
  • The Friend? "not my problem."
  • The Lover? "not my problem"

The verdict

Each group had a different order of culpability (except for one table who refused to rank) reflecting the individual values and assumptions of people within it. Most agreed that 'just doing my job' was not a good enough excuse for the guard but was generally OK for the boatman. There was much variation of opinion for everything in between.

We agreed that differences in opinion were not necessarily incorrect as long as we remained aware that none of us enter a situation entirely unbiased or without assumptions and that these colour the way that we perceive and interpret data.

We compared the story to the current state of the NHS. In what way do our patients sometimes resemble the Baroness? Had we ever witnessed similar stories being played out in our day-to-day lives?

Do we have a collectively responsibility to change the system rather than point the finger?

Ground rules

Before we progressed too far into the course, it was important to establish rules of conduct and ethics for the remainder of the year. We produced the following five rules...

1. Chatham House Rules: In order to create clear lines of communication and break down inter-professional barriers we needed to be able to speak freely and without fear of repercussion. That courtesy applied for both fellows and the invited speakers.

2. Be Present: We agreed that each of us would try to remain focussed on the task at hand. Travelling long distances to the course helped in this respect by creating a physical and mental distance from our day to day lives.

3. Be compassionate: The amount of new information can be overwhelming. We agreed that, at any time, a table can request a break from the exercise and the whole room will pause. An individual can also signal they need a break without pausing the exercise. We termed these signals ‘cake’ and ‘cupcake’ respectively.

This is a pretty apt representation of how we felt after day 3

4. Be respectful of how we are present: We acknowledged that whilst individual input may fluctuate throughout the days, each one of us has made the deliberate choice to be here and all input is valid and welcomed.

5. A right to veto: In order for everyone to have a voice, everyone’s voice must carry weight, even if it is not the majority opinion. A difference of views should be welcomed and discussed rather than swept over.

Traffic light rules of engagement and discussion
Better yet, we had a conch!

The Four States (below) - All of us where coming in to the course with different feelings. It was suggested that we might identify with one (or more) of four states. How we felt would shift constantly throughout the year but it was important to be aware of what 'state' and be open to sharing this with the group. (Clockwise from top left, 'the vacationer', 'the prisoner', 'the explorer', and the 'sophisticate'

It wasn't always clear to ourselves which ones we fell into.

The First Expert Witness

Professor Steve Field

The big picture
We need to grow local leaders, and make the values of the NHS known to everyone
Most health inequalities are due to social issues and government rather than actual issues that that can be dealt with by the NHS
Search out the people who value change

It's safe to say we weren't prepared for our first expert witness. Slightly starstruck, we meekly sat in our large group circle as Steve came in and gave a potted and at times slightly controversial summary of why the NHS was where it was. He also gave us his thoughts on what it would take to make it right.

When asked questions, he fired one back at one of our number. What did we think?

What followed was a thought-provoking discussion. Some felt slightly vilified that Steve's views did not necessarily match their current experience on the shop floor.

But the top-down view of the NHS structure segued nicely with the next exercise.

Get out there and change the world

A Case for change

The NHS has undergone constant revisions. Whilst still recognisable to its original form, both the world and the population is constantly changing and the NHS does not exist in a vacuum . The next step was to look to the past to see if there were any patterns.

To give context, as a group we constructed a large timeline looking at not only the NHS, but significant world events from 1900s to present day and our own personal timelines; when were we born? When did we start training?

In the end we had something that looked a bit like this...

We recognised a cyclical pattern between the world stage and events at a local level. There was a repeating pattern of looking outwards and expansion which often generated conflict in the process, both internally by the people who felt 'left behind' and those on who's territory we were encroaching.

This usually resulted in collapse, as our collective ambition outgrows its blood supply, resulting in periods of increased introspection and nationalism and, at its extreme, xenophobia.

We realised that the NHS lay slightly behind most major societal shifts.

By the time globalisation took off, the NHS had become largely decentralised. Now it appears we are on the cusp of the reverse again.

This pattern appeared linked to major political cycles which in turn were influenced by the global stage, itself influenced by and influencing the views of each generation.

Each time a new party came into power, there was a tendency to reinvent the NHS to fit with current ideology.

We saw how those who grew up in fortuitous times prized stability as the established system works for them. Those who grew up in less favourable climates favoured change.

Technological Innovation

It wasn't all bad. Global events (usually wars) often drive technological advancement which in turn affects both society and the NHS.

The internet has connected people and information in a way that has never been achieved before and as a result, the rate of advancement is accelerating.

Treatments are available for many more conditions and life expectancy is increasing, with people living longer with chronic diseases. Whilst an overwhelmingly positive thing, this has led to increased pressure on the health system. In the past, 'treatment equaled cure' but that is no longer the case.

a very simplified diagram

Expert Witness

Patient Experience

Jocelyn Cornwell - Founder & CEO Point of Care Foundation

Every product and every service has three distinct elements

  1. Performance - how well it does the job, and whether it's fit for purpose?
  2. Engineering - whether it is safe and reliable
  3. Aesthetics - How it feels, and is experienced
Improvement has to come from within not from policing and regulation

Schwartz Rounds

Schwartz Rounds provide a structured forum where all staff, come together regularly to discuss the emotional and social aspects of working in healthcare.

They help staff feel more supported in their jobs, allowing them the time and space to reflect on their roles. Evidence shows that staff who attend Rounds feel less stressed and isolated, with increased insight and appreciation for each other’s roles. They also help to reduce hierarchies between staff and to focus attention on relational aspects of care.

The underlying premise is that the compassion shown by staff can make all the difference to a patient’s experience of care, but that in order to provide compassionate care staff must, in turn, feel supported in their work.

We heard case studies of patients where the small things weren't taken into consideration. How it was the 'whole' system, at every level, that can fail patients; from personal/professional to system-wide processes, performance drivers and culture
We heard about the sutton red bag initiative; a simple, grassroots solution to ensure patients did not become separated from their dentures, saving the hospital thousands of pounds in replacement dentures or treatment of aspiration pneumonia.
How do we make all patients' have a positive experience? we can't make all patients' happy
Can we design empathy into services?
why do patients use services as they do? And why don't they use them as clinicians expect them to?
The next wave of change being a culture shift of patient experience aligning with the same level of importance as patient safety and clinical outcome.

Together we are stronger

Epistemology exercise

We split in 5 groups/professions, broadly these groups were split into Therapy, Medical, Nursing and Midwifery, Pharmacy and Paramedics.

Each group had to collaboratively comment on each of the others groups. Answering each of the following questions...

  1. What we think you think of us
  2. What we want you to think of us
  3. What we think of you
  4. What we never want you to say to us
It was a really interesting exercise. Some of us recognised accurately what the other professions thought of us, although many of us over exaggerated negative aspects.

We were all surprised of the positive nature of everyone's thoughts, and learnt that such an exercise enabled understand and compassion towards each others' roles and feelings, and how in the future we should promote the continued drive towards more joined up and multi professional working.

Together we are stronger

Day 3

how organisations get work done

Expert Witness

Michael Wilson CBE

How do you sustain values/culture and permeate it through the workforce?

  • Value all the people you work with
  • Focus all your time on the patient experience, patient safety and quality
  • Constancy and consistency
  • Allow people time to innovate and push boundaries
  • Quality. All the time. Even when people aren't looking
  • Pursue perfection. Make small changes and build up

Climate and culture; values and beliefs - the best model in the world won't work without the right foundation.

Throughout his talk, Michael emphasised the importance of creating the right climate throughout an organisation to allow a culture of positive change and innovation to develop. The biggest challenge to the NHS was not money but the workforce; retaining them and keeping up morale. By giving people buy-in and ownership of their work, you empower colleagues to innovate at all levels within the organisation.

"Theory is great but if you can’t make it work at a practical level, it won’t work."

As we discovered later, the personality types that tend to become policy makers are often very different from those working on the shop floor. Yet the people on the ground are often those who know the most about what's going on in their particular area. Policies perceived at as unrealistic or 'out of touch' are unlikely to gain traction or at best grudging compliance. Some people need to see change to believe it so the ability to make changes at ground level is important.

Administrative staff and executives are encouraged to visit the wards and operating theatres; there should be an end to disconnect between admin and clinical work.
Put the patient at the heart of everything you do.
Fellow observation - "If something happens often enough, it just becomes an accepted norm."

In contrast, throughout the UK there are entire operating theatres that have been funded, built and never used.

The Role of the STPs is to get the right people in the right places. Seek out the people who want to make a change. Build a coalition of leaders determined to drive change through and act as role models.

how do we train and develop the workforce to work differently

But don’t just make change for the sake of it; everything must be evidence based.

Fellow observation – "the names of organisations change, the people at the top and the bottom of the structure often have a high-turnover rate but for most of the workers, nothing much changes and nobody even really notices."

"The people who made CDs were not the people who invented the tape recorder"

Disruptive innovation is under the radar, not as good as the existing but there because of an absence of something else

How do we detect New Models of Care?

A Model of Care has to start with understanding how it adds value
As opposed to an existing system with bits stuck on

Have any of these changed?

  • - Engenders coalition
  • - Provision of advice
  • - Routing (including exit)
  • - Assessment/diagnosis
  • - Transport provision
  • - Intervention (not just treatment)
  • - Coordination and systems management
Still a bicycle...
Ideology trumps evidence every time

A Model of Care has to start with understanding how it adds value

  • Chains - bring things together, or fix broken things.
  • Solution shop - solve unstructured problems, what needs fixing? for example A+E is not Primary Care's triage
  • Networks - getting people to be part of the solution

Who are we?

The Myers-Brigg Type Indicator is a tool that helps us understand who we are so we know how we interact with the world and how the world may perceive us. Through understanding ourselves, we learn how to adapt our style to interact with others more effectively.

We spent time marking our Myers Briggs indicator types. As a group we were quite scattered across the sixteen types. We saw how professions often attracted similar personality types. However often the ‘odd one out’ was the most able to see areas needing improvement.

We were divided into two groups; the Introverts and the Extroverts. The split was roughly 60:40. Each group discussed amongst each other what questions to ask the other group. It was interesting how the groups talked; introverts would talk one at a time and say little; extroverts talked over each other but were able to keep track of multiple conversation streams and thought 'out loud'. This was a reason why sometimes the two types misunderstood each other.

Remember this? The introverts loved it

The question we wish we'd asked: "are you surprised by some of the people you see in this group?"

The other paired functions: Intuition-Sensing, Thinking-Feeling, Perceiving-Judging had less effect in day to day life but one exercise revealed how differently people perceived the world

'Describe this bottle"

How to manage your darzi

Preparation for Inquiry

In pairs, we took a walk. Taking turns, we discussed what we understood of our project to date and asked questions to find areas we hadn't yet thought of.

In teams of three, we discussed who we felt we needed to talk to in order to understand our projects. We exchanged contacts where necessary so that everyone left with a plan.

We were informed the next step was a deep dive.

Our preparation was to ask questions

and find the ones that worked

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