When over efficiency means less productivity

I was, at first, speechless when I heard about an NHS friend who spend part of her work days perched on the edge of another colleague's desk because there wasn't enough space for her to work. I hadn't heard about the Government Policy, introduced in 2011 that for administrative areas, there should be only 8 desks provided for 10 people - this is called Agility working. Huh?

You can read about this cost saving exercise here: https://www.gov.uk/government/news/government-property-strategy-cuts-millions-in-costs If you want to see the NHS business case document on how it is built into cases then you can find this here (item 23): www.england.nhs.uk/wp-content/.../11/five-cse-bus-mod-chck-lst.docx 

Now I am all for cost saving and inefficiencies but there's something not working if someone is trying to do their job balancing their laptop on the corner of a desk, wires trailing, knees wrapped round edges etc. Apart from anything it's not respectful.  I'd not put up with it, but then, even in the administrative areas of the NHS, there's fear and concern for jobs.

[sigh]

I've not blogged for a while. I was waiting until I had something I really wanted to say.  I think it's time to speak out and to speak up. So I'm going to start doing just that.

It takes courage to be positive in times of change

When is feels like someone has tipped all the water out of your glass, it's difficult to take the "glass half full" positive approach.  But if the glass was more than half full then maybe losing a little of the contents is right, as horrifying a thought as that may be.

I'm obliquely referring to all the changes in the NHS in England in the last few months. I found March a very depressing time to be on Twitter as the chorus of disapproval for change grew louder, and at times, more aggressive. In the end, the changes have happened. What happens now is a matter of attitude.

Complaining is easy. Coming up with the shift in mindeset that's required to make the changes work is far more difficult. I'm not prone to Bible quotes but there's a good one from Matthew 7:3 "And why beholdest thou the mote that is in thy brother's eye, but considerest not the beam that is in thine own eye?"

The challenge for those complaining loudest now is to be sure that what they're complaining about is not something they have a part in. It's time to examine the fears that lie behind the complaints and to help those who see only the negative that there are patients and communities who want to make the changes work for them.

Paper: Implementing culture change in healthcare; theory & practice

This excellent paper on implementing culture change in healthcare; theory and practice was published 10 years ago. It's still relevant and there is no need to start another cohort of research on the theory now that "culture" is a big theme for the NHS.

Readers of this blog will know my aversity to the continuous stream of repetitive research - with insufficient action to put it into practice.  Culture is a difficult topic. The word defies easy definition  yet it's bandied around as both a devil and panacea - a cause of and a solution to the problems facing the NHS.

This paper is available free of charge and is worthy of a read and discussion with your colleagues.

When an app becomes a care plan and a pathway co-ordinator; Asthma AWA

This is a guest blog post from Howard Last. He contacted me after my spate of reviews about healthcare apps. He's provided more information about the asthma web app AWA.  If you'd also like to guest blog then please contact me.

Putting the ‘technology horse’ before the cart was our aim in developing the asthma ‘web app’ (AWA). It is, regrettably, so often the other way round. I work as a GP in an inner city area and was acutely aware of the needs of patients with asthma and the shortcomings in provision of asthma care. I also have an interest in I.T. so it wasn’t long before I wondered how we could use I.T. to address these clinical needs. Making use of Web 2.0 we developed an ‘app’ which tackles the major issues contributing to poor asthma control: inhaler technique, patient education and provision of a care plan.

The provision of a care plan in particular is one area which needs improvement. The AWA control plan is the key component in the application. Patients without a care plan are four times more likely to need an acute admission with poorly controlled asthma. Yet, only one third of asthmatics have a plan. The AWA makes it much easier for a GP or asthma nurse to provide a personalised plan for a patient during a consultation. Subsequently, patients have access to a web-based version of their care plan either through PC or mobile devices. But it goes one step further. The AWA care plan, unlike a paper-based version, adapts dependent on the patients asthma control, prompting an increase in treatment with poor control or allowing a ‘step-down’ with good control. In other words it promotes self-care.

The AWA also provides an alternative healthcare pathway to the traditional model where patient care takes place in GP surgeries or hospitals. The AWA allows the healthcare professional and patients to interact remotely. This is particularly valuable for the ‘difficult to engage’ patient. In asthma care this translates into teenagers. This is a group who are always resistant to invitations to asthma clinics but for who the use of a mobile phone or tablet is second nature.

I think the success of an ‘app’ depends on two simple principles based on need and data handling. First, there has to be a clear clinical need for an ‘app’. Secondly, collecting data is not in itself sufficient.  Doing something useful with the data for the benefit of patients is the crucial step. I believe the AWA passes these tests. Whether it is innovative, I will leave you to decide.

Howard is happy to be contacted if anyone would like more information about the AWA.

Outsiders cannot change NHS Culture - only NHS staff can do that

The responsibility for a change in behaviour and subsequent culture in NHS organisations, lies with the staff employed in those organisations, not with any external body.

NHS Organisation: the NHS is not an organisation by most definitions  It is not a singular corporate body..

Definition of "Organisation" from Business Dictionary:

A" social unit of people that is structured and managed to meet a need or to pursue collective goals. All organizations have a management structure that determines relationships between the different activities and the members, and subdivides and assigns roles, responsibilities, and authority to carry out different tasks. Organizations are open systems--they affect and are affected by their environment."

The NHS is a system, and one composed of formal organisations (with differing structures) and informal networks and collaborative structures that include other government bodies (social care) as well as NGO's and social enterprises. The Department of Health is not the NHS. Nor are consultancies, improvement bodies (acting as consultancies), regulators etc. These are their own organisations, with their own cultures with underlying behaviours, that also need to change.

It's easy to tell someone else or another organisation that they need to shift their mindsets and behaviours. However, following the Francis Report, the best place for everyone to start is by looking at their own teams and organisations, assessing their own culture, and making the efforts to change their own personal and group behaviours. This needs to happen not only for those organisations who deliver health care services, but also those organisations that are government funded to support the delivery of healthcare.

For these "outsider" organisations, the cultural and behavioural questions need to be reflective of their own internal behaviours and the impact these have had on NHS delivery organisations. They also need to be an honest appraisal of the cultural norms that exist within, and how these may be played out in the way they "support" the NHS Delivery organisations.

No-one needs a consultant or a clever framework to do these reviews, nor an expensive and complicated change programme. Large change initiatives operate as a displacement activity for not facing up to the details of the changes required. Real change starts with two people sitting down, telling their stories to each other, listening, mulling over the behaviours that may need adapting, then committing to have a go at changing their own behaviour, and to including others in their conversations.

Redundant? Starting up on your own? Free Business Planning Templates

The redundancies notices have been issued. CV's are being spruced up and the calculators are out as many NHS staff figure out whether they can work under their own steam, on contract, as consultants  by starting up their own business...

The one most important fact of a business, for which there are no exceptions, is "Cash is King".

Even if you think your new organisation you're starting up will be subbed by the Department of Health or some other contract - the same statement holds. You can't pay staff, your telephone bill, you rail-fare etc, unless you have cash in the bank.

Cash is not a promise of work - there are plenty of those that don't deliver/
Cash is not an invoice - though if you're desperate, you can ask the bank to give you a loan against it.

Cash is when the money is in the bank account.

Business planning is essential if you're planning to go on your own. You'll find that the plans have more meaning than any plan you've done for an organisation  You need an in year plan and at least a 3 - 5 year plan that sets out your strategies and goes down to the level of cash - in the bank.

To help you, I've complied a list of free templates you can use for your business planning processes:

1. There are 5 excellent plans, check-lists, budget summaries etc available from Invoiceberry.  As with all plans you'll need to edit and customise to make them your own, but the details are covered in these.
2. Microsoft Office has a number of templates for download.. They have a SWOT, 5 yr plan, business plan, balanced scorecard and an excellent waterfall forecasting model which analyse profit and loss, and balance statement each month (remember, cash is king).
3. Bplans has templates for different types of businesses - in case you are feeling like opening up a restaurant or a bicycle repair shop.
4. Teneric has a comprehensive suite of tmeplates, including a free course on how to write a business plan

The words innovation and improvement can be misleading

If you want an idea or activity to be judged as good, then label it as an innovation or an improvement. Correct?  Well, I'm not sure it should be, but it seems that's what happens. I've been wondering why it is that the words "innovation" and "improvement" are assumed to represent "the good".

At a high level, there is an ethics issue; to whom does the "good" belong? New ideas often stem from crises, and crises are often either sourced from or produced by competition. When one side creates an innovation, the other side loses.

At a more detailed level, what worries me is that by labelling an idea or activity using words that come with the assumption of good, is that we:

• fail to evaluate whether the idea does what it intends (fidelity; more about fidelity here)
• fail to check whether there are unintended consequences in applying it
• fail to understand the drive of the person or organisation behind it
• urge the spread of a "good" practice, without assessing its value
• just accept; and the more we just accept, the more we open the floodgates to ideas and activities which may no longer be what we need

There's a lot of talk in the NHS about the need for "innovation". It will be good when this is grounded into discussion about the problems that need to be solved and then the ideas and activities being introduced to solve them. Solutions need to stand on their own right, not be labelled to give them credibility.

Cutting the cloth does not a slimmer NHS make

The NHS in England is undergoing a fundamental change  It's driven by the need to cut the cloth - to cut the expenditure. The trouble is, if the body of the organisation is still fat, then trimming the clothes will neither a pretty picture nor a happy organisation. The body needs some work.

It's a little like telling someone who is used to living a life where they can buy designer clothes  shop for the best cut in steaks and live in the best areas - that they have to buy from Primark and live in a less desirable area.  Obviously this is not an ideal situation. But it is one where the person starts to live within their means. Yes, it means life will never be the same, but if the person doesn't make the shift then they may face bankruptcy and lose everything. Surely it's better to take control and create a new life that is sustainable.

The NHS has a lot of fat in it. There is waste, despite the doomsayers who tell of the end of the NHS due to budget cuts (cloth cutting). This fat often isn't obvious (it is hidden deep within the organs of the organisational body, often in small streaks, but there nonetheless. When I can buy a ream of paper cheaper than an NHS organisation - there is waste. When I or a member of my family has difficulty in getting discharged from outpatients - there is waste.

I'm on my personal mission not to become part of the obesity epidemic. I am pleased to have got through a number of (healthcare...) events without resorting to the biscuits and pastries. Maintaining an exercise regime in the snow is difficult - but not impossible  I know that buying clothes two sizes smaller will not cure what's lying beneath them.  A radical shift in behaviour is required from me.  And so for the NHS - a radical shift in how services are designed to meet the future needs of future patients is necessary. While I commiserate with the pain staff in the NHS are going through, I do hold out hope, as a patient, that eventually the cloth cutting will move on from losing staff to rethinking the way care is delivered.

3 reasons why UK healthcare should not copy US innovations and improvement methods

I've nothing against the US, it's healthcare system and the methods used by various US organisations to improve their outcomes and processes. I don't live there so my opinion on their healthcare system doesn't matter. What is my business is the importing of US methodologists and solutions into a different context.  At a high level, learning new methods such as the Improvement Model is helpful, but at a more concrete level, copying "what worked in the USA" into the NHS will always be fraught with difficulties.

Reason 1: The USA outcomes are worse than the UK.
The IOM has released a new report US Health in International Perspective; shorter lives, poorer health. The facts are stark. US citizens die younger than their peer countries, despite paying more. Crucially, the report suggests that 20% of avoidable mortality is due to poor healthcare (rather than system related issues or behavioural choices).  Specifically, the US is worse than many countries in infant mortality & low birthrate, injuries and homicides,obesity & diabetes,  heart disease, chronic lung disease.

So why are we copying "solutions" from a system which is providing for worse outcomes than ours?

Yes, it can be argued that some care processes have better outcomes, but even then, there are difficulties. For example, it's widely touted that men with prostate cancer live longer than men with similar condition in the UK. If you look into the detail, yes, US men get diagnosed earlier - but they die at a similar average age as men with prostate cancer in the UK; the US men just had longer with the diagnosis, the treatment and the cost. More details on this and similar topics on the Cancer Research Science Update Blog.

Reason 2:  US model is based on cash for activity
The incentive for the majority of healthcare services is to provide more activity as a means of generating more income. This leads to overtreatment. Sharron Browlee's book "Overtreated; why too much medicine is making us sicker and poorer" is an excellent expose on this topic.

I had a debate with a US improvement consultant yesterday about why the NHS may not be rushing to implement rapid response systems in hospitals. We have a different value system, we have a different set of economics, and a different culture about death and dying. Solutions that work in US hospitals may not be the best ones for our NHS. Yes, we still need to resolve some of the underlying issues - but I hope we can do so in a way that fits our own culture, social and economic constraints.

Reason 3: The opportunity for delivering change & improvement in publically (and part-private..) funded health system far outweighs the private led US model.
Even though the NHS is under pressure to privatise part of the healthcare services, the fact that we do have a publicly driven system, connected to social care as well - means we have an incredible opportunity to devise solutions to problems that are truly radical. While we fuss about the speed at which patients are supposed to get electronic access to their records, and how to link them with hospitals - at least we have electronic records. We have register of people with conditions, and many good primary care organisations use these to do their best for the health of their local population.

I sometimes feel that whilst we are in the embrace of US-led improvement and change methodologies we are not devising ones that will make the most of our specific context. A good start is the NHS Change Model, which is sufficiently bland yet comprehensive, to provide useful and reasonable guidance for change.  It's not earth shatteringly clever - but it is one for the NHS, by the NHS, and I believe will be helpful for the NHS.

Is #wenurses THE NHS social movement?

I’m late to the party - #wenurses  has been around for a while; but then. I’m not a nurse. I discovered #wenurses by accident and lurked in the background of a few of their weekly tweetups.  What a joy.  Usually my Twitter feed “nhs” search column has an ever-increasing stream of negativity and attacks on the NHS.  #wenurses is different.

#wenurses is a way for nurses of all disciplines and interests to connect using social media. They can get training in using Twitter, have blogs, resources and are active with tweetups, workshops and blogs.

#wenurses tweetups are Thursday evenings at 8pm. The first tweetup of 2013 was a delight in the endless positive comments about the successes of 2012 and filled with ideas on what to do in 2013. I loved the way someone suggested it would be good to get a CEO to join them. Someone replied mentioning the twitter names of those who may be good to ask. By the end of the tweetup a number of those CEO’s were joining in the chat. That is digital democracy at it’s best.

These are nurses who don’t talk about what’s wrong, or complain about the reforms. They are asking questions about how they can be better at what they do, how they can get help in understanding changes, such as commissioning.  

Is it a social movement? I think it is because:

• There is no organisational or policy imperative that they come together and do something
• There is a simple website around which they can organise themselves on social media; it#s #wenurses website and isn't a subset of another organisation. The branding and identity is clear.
• There are no apparent rules, other than a very good statement of appropriate behaviour for nurses using social media
• It’s self-organising around topics
• It’s driven by the passion of individuals
• The purpose is clear; to use social media to connect the community of NHS nurses, to share knowledge and to provide support.

The friends and family test comes into use in the NHS in a few weeks. This is where patients will be asked if they would like a member of their family or a close friend cared for on this ward, in this hospital, by this doctor etc.  When I’m a patient, I’m going to be looking out for the small #wenurse badge. If I see a #wenurse mug on the desk then I’ll know already that this is a good placed to be.

What happens when your quality improvement project is too long

Quality improvement projects have traditionally been 18 months long - at least that's my experience in the healthcare in the NHS in England. I expect they are that length of time because it is about the right length of time to second someone into the role of project leader. After 15 years of experience, I believe this is far too long for a QI project.




The problems with 18 month projects

• they take 18 months... 
• over-work the process; carry out redundant tasks to fill the time (every project leader wants to look good)
• too much emphasis on innovation and clever solutions, that are difficult for others to adopt
• difficult to maintain focus over so many months
• many clinical staff are unwilling to commit to the project
• the context changes  reforms, new organisations, new care methods - all come into play during the period of the project

Instead, I advocate the 90 day project. This is enough time for the average team to implement the average type of changes; and average matters. Most teams can imagine 90 days and are more likely to commit to making the effort to improve a targeted area. They will know within 90 days whether their efforts were worth it. 90 day projects need lots of planning by the project leader, though this can be done with minimal intervention with the clinical team, leaving them to spend more time with patients. They are best done with known best practices that are known to work in a similar context.

For more info on 90 day projects from this blog:

1. What are 90 day projects
2. How to implement 90 day projects

Or hang in there for my new book on 90 day projects which will be out in January 2013.

Who does “Improvement”?

When I ask national and regional teams what their purpose is, they usually say something along the lines of “to deliver improvement in our health system”.  I’m not so sure about this. The people who deliver the actual improvement are those who make the changes. What advisors, consultants, internal change groups, OD departments etc. do is to enable and support others making the change. It’s perhaps a rather arrogant stance for those wearing an “improvement” badge to think they are making the improvement.

To be an improvement leader is to sit in the mist of humility, where your personal satisfaction comes from seeing others develop, from watching them stand on the stage and share their experiences, and from knowing that the success of others is sufficient to satisfy one’s own ego.

The improvement leader is a sherpa, whose role it is to support, and when the time comes, to applaud the team’s success, quietly, from the shadows.

A Mandate for NHS Improvers?

The new NHS Mandate sets out the standards the patients and their families should expect. It is both strategic and operational. It’s not perfect but what it does contain is specific and difficult to argue with. Yes, there will always be things it hasn’t covered, but in the end, it’s better to have something than nothing.

What might be a Mandate for people whose task it is to support he implementation of the Mandate, to work with CCGs in making local changes and whose role it is to help individuals and teams create the new NHS.  I’ve drafted a few thoughts on this mandate, please add your comments if you have additional items to add.

The NHS you support should expect interventions that:
1. deliver a good return on investment
2. take the minimum of staff time away from the patient
3. are directly connected to the CCG or provider business
4. are for the user of the intervention
5. focus on the NHS rather than other systems national or internationally
6. practice what they preach (QIPP especially)
7. others?

Hospitals as prisons

To compare a hospital to a prison is challenging. Maj Rom, leader in Sweden for the project to improve the experience of life for the Elderly, used this comparison to wake us up, to make us think, to challenge our perceptions.

I found this a shattering concept, but the more I considered it, the more I realised we can learn from the challenge. Where else, toher than in a hospital and a prison do we:
• Have rules regarding who may enter, who may visit and the times of this visit (and even what they may bring in with them)
• Segregation for those with problems (like infections)
• Rows of beds, organised like cells, with a co-ordinating point for the “guards”
• A hierarchy that determines behaviour and where the inmate/patient is the recipient and often seen as the lowest of the low – to be done to be organised, to have rules explained
I could go on, but you know how the list continues. You may even discover that some of the aspects of prison are better than hospital – privacy, own TV, better food etc.) Try it out at your next meeting.  Or better still, walk around your nearest hospital with the eyes of an alien comparing it with a prison.

The challenge is not to make the comparisons, but to figure but what this means to us.  It’s not about criticising hospitals but it is about engaging with what we have created and finding the strength to change what we don’t like.

How do we tell our Emperors and Empresses that we know they are naked?

Image from: www.emperorerswithoutclothes.com

The fable about the Emperor who had no clothes is well known. He believed he was wearing sumptuous velvet adorned with jewels, but in truth he was naked. His minions played along with him, "dressing" him every day and complimenting him on his attire.  Then one day, someone decided to tell the truth...      

How to diagnose whether you are an emperor or empress

1. Do you have strong beliefs about something?  What people or processes do you have in place to ensure you are not believing your own beliefs? For example, a mentor or critical friend who has the strength to point out when you are dashing about naked.
2. Do you have "minions" around you who are constantly agreeing with you, forwarding your tweets, nodding their heads in meetings and running about in the shadow behind you.  Can you remember the last time someone really disagreed with your point of view? Does it happen often? Do you ever disagree and have a constructive debate with someone?
3. Do you talk about your "clothes", are you constantly changing them, adding jewels etc.  The endless focus on the clothes, and the changing thereof, can make it difficult for "minions" to comment.
4. Do you marginalise the person who disagrees with you. This may happen without any conscious thought. You could be picking up a signal and then ignoring them out of fear they may point out what you already know.

A number of CEO's have mentioned to me that one of their greatest fears on appointment to their role, is that staff no longer tell them the truth about what it happening and instead tell them what they think they want to know. They then set up ways to counter this problem.

If you are an improvement leader in healthcare  do you have a way to check the extent to which your clothes belong to an emperor or empress?

        

Redisorganisation in healthcare: the theory and the practice

A good friend, Bill Russell, tweeted a link to "A surrealistic mega-analysis of redisorganization theories" published in the Journal of the Royal Society of Medicine, December 2005.  Yes, it's a Christmas edition spoof, however, there is some unnerving truth underlying the splendidly irreverent - and creative - paper.  I share it nervously, as I wouldn't be surprised to find it turned into a PowerPoint and a half day course being run to teach people the theories.

The paper got me thinking about the tendency of Healthcare Improvement Leaders to grasp at the latest theory that comes their way, further confusing the people they are expected to serve with their "leadership".  Recently I have encountered an exhortation about the need for consistency and a single model for change in the NHS; countered by the push of new ideas and theories, which dilute this message.  As well as new concepts being presented as though they are the next best way to make an improvement / support change; the concept is a concept - it has not been fully tested.

The frivolousness and scattergun approach for supporting healthcare staff and their organisations is unlikely to be a useful one.  My concern is the endless search for the quick fix is confusing people. In addition, when one theory ends up not working in practice, then I'm not seeing the evaluations, reviews and sharing of lessons (as in role modelling learning and improvement). Therefore each new concept is being built on an ever-weakening foundation.

The value of of those who lead improvement and change in healthcare  I believe, should be based on the depth and pervasiveness of change they support, rather than on the number of new concepts of pilot projects they put into the system.

Feedback needs to be both ways, especially for patients

Feedback is important, in almost any context I can think of. In quality improvement we are continually asking staff and patients for feedback about their experiences. I make a point of completing feedback forms that are sent to me because I believe that my opinion will - somewhere down the line - count.  Mostly this is on trust as I never get any feedback to me as to whether my involvement has been worthwhile.

Asking me, the patient for feedback is giving me the impression that you believe my views are important  Not letting them know me results of my feedback is, sort of, forgiveable (it would be nice to what "what happened later").  But what is really difficult to get to grips with is on-line feedback which is then not answered. NHS Choices runs an excellent on-line feedback scheme where patients can leave their notes about their experience.  In many cases the organisations respond with an explanation. And for many patients this is enough - to know that someone cares about their experience.

For my own GP practice there are a few pages of negative comments from patients whose experience is an issue. The fact there are no recent replies to these comments leaves me feeling like wanting to leave a note about there being no feedback...

Feedback: it works both ways.

Five iPhone apps the NHS can learn from

Many healthcare organisations are getting on the “app-wagon” by repackaging some of their regular website material.  In most cases, the “innovative” bit is the use of the iPhone’s GPS function for maps. Is this innovation? Not for me.

I’m on the lookout for apps which redesign interaction with health services, that support patients in caring for themselves and their families – and basically, ones which have an underlying brilliant idea that can only be implemented on a smartphone. 

In the end I didn't find any apps that lit me up – though I did find some that gave me ideas for apps that could be developed.

Wounds by BSN Medical Ltd, May 2012, UK only, FREE

You use your iphone camera to take a snapshot of the wound, then use the symbols to categorise it by wound need, depth and exudate level (for the non-clinical this means how bad, deep and weepy it is).  Then the appropriate dressing is suggested – and of course, this is their own brand of dressings. I’m not into promoting one type of dressing but this app is IDEAL for the NHS. Why hasn’t anyone produced this for the reduction of pressure ulcers – linking to the NHS Supplies dressings?  What I like about this is no improvement project is required – implementing an app will redesign the process of assessing and treating wounds/ulcers in the most fundamental way.

iScrub Lite, Free, May 2010

The premise is good hygiene and this app records observations and lets you email those observations. Whilst I am sure this is for audit folk, I can imagine that in the hands of patients (maybe lend them an iPhone while they are in hospital) it would have a big impact.  This would be fabulous if it was populated with the addresses for the contacts in each healthcare organisation in the NHS.

MedCrowd, Oct 2010, Free

This is an app designed to crowdsource medical opinions. I suspect it’s not really taken off but the concept is excellent.

Patient Journal, Free, June 2010

I like this because it is a place I can keep all the notes about being in hospital. The only problem is it really needs to be managed by the carer as the patient may be too ill to use it.  I think this would be good for longer temr patients or just for patients in general to keep track of their interactions with healthcare.  It works because it provides a structure only and doesn’t try to give me advice.

Mixed Messages, Free, June 2012

This is a training app aournd doctor-patient communication. I like the concept and it makes sense for much of the training programs that go on in the NHS to be put into a format like this. It’s simple, focused and not overworked.  No more books, manuals, workshops or PowerPoints!

Review of NHS iPhone apps

A number of NHS “innovators” are up there with their iPhone apps. I say “innovators” loosely as most of the apps are no more than websites in an app – useful but hardly innovative.  What’s more interesting is the lack of apps, even the most basic ones, from one of the world’s largest systems.

The NHS brand is one of the most well known in the UK, and using it and looking after it is important. There is now even a Brand Manager (c.£90k post) on the National Commissioning Board. From my days as the advertising manager in Esso, I know how important it is to make sure logos and accreditations are used properly.  My review of apps discovered many people using the NHS brand when they are not the NHS, and others in the NHS are not using their brand at all.

I chose the apps that appeared under a search for “NHS” on iTunes AND where there was NHS in the logo or title of the app.,The apps listed are all free.  

  

NHS Direct’ health & symptom checker

One of my favourite NHS apps and one I have used. It feels like the whole of NHS Direct is in my pocket. The feature of finding, for example, a pharmacy nearest to where I am standing is very useful. Comprehensive, easy to use and a flag bearer for app quality.

NHS Drinks Tracker

Not entirely clear but I think this is from NHS Choices (they could use their branding on the app logo perhaps?). Interesting to play with but it looks like it lacks flexibility to suit a wide range of users – as verified in the comments for the app.  Maybe an update is required? There’s also a Dept of Health Change for Life Drinks Tracker (do we need duplication?).

NHS Quit Smoking

Branded in the app as NHS Choices. I like the way it counts the amount of money saved according to the number of days you go without smoking.

NHS BMI healthy weight calculator and tracker

Another NHS Choices app. Clear and easy to use. Like the other apps in the series, it looks from the comments, like it could do with an upgrade.  There is stuff competition in app-world for BMI calculators and food intake / exercise trackers, so there needs to be a good reason for someone to use this one.

NHS Give Blood

From the NHS Blood and Transplant service, though confusingly the app logo doesn’t use the NHS branding. It’s a map function of where to give blood locally. I can see this being very useful in a crisis.

NHS 24 MSK help

Hmmmm, pink logo and very strange branding. Developer is NHS 24. Looks like an exercise app. Didn’t inspire me to download it and try it.

UK Clinical Trials Gateway (NHS Institute for Health Research)

Nice – I like it when the name of the app says what it is about and who it is from. As they say in their blurb, it’s for everyone, patients included, and covers the portfolio of clinical trials registered in the UK. I expect I can also get this off a website somewhere, so the innovation here is packaging it all up – a but like NHS Direct.  There is evidence of the app being updated which also enhances its credibility with me.

NHS Moodometer

This one took some detective work to understand. It’s an app to measure your moods. Useful if you’re in the process of understanding your own moods. It has the NHS logo on it. It comes from 2together NHS Foundation Trust – which I found out is in Gloucestershire – not obvious at all who they are and what they do from their name!  If they are using this app with staff then we need to know about this innovative use of it…

NHS Bristol and NHS Yorks & Humber

This is a well-designed organisational app that looks like it can be a standard one for many NHS areas. It’s more than a replication of their website and it is wonderfully designed for us.  It covers ICE (in case of emergency), your personal reminders and notes, where to find which service and cleverly uses the clour coding of the campaign to reduce A&E attendances (the thermometer). This app has a purpose which goes beyond advertising services.   Will need an update after all the structural changes.

My visit to Guys’s and St Thomas’ NHS Foundation Trust

Excellent. Designed for the patient, this app covers appointments, hospital information and maps.  I like the fact the name of the app says what it is for, and the integration with GPS on the phone is useful.

NHS Tameside and Glossop

Not certain about the logo use but the app is one that has broken away from the regular brochure / map / information approach.  Instead it is disease based giving information about conditions and pathways. I am not sure who is the intended audience? The name of the app left me thinking this was about the organisation but the contents are something different.

Welcome to St George’s Hospital

Another one with an app name that is useful. This is another information type app. I found some of the colouring a bit difficult to read and the design is rather poor. There’s a nice facility for providing feedback to the Trust – though I haven’t tested this.

NHS ActiveME

An app from the Royal Hospital for Rheumatic Diseases NHS Foundation Trust allowing the monitoring of daily activity levels.  Nice. Nice. Nice!  Beautiful design, easy to use and I love the graphic reports.

NHSCovWarks

Hmmmm apart from the rather short hand title, I’d not know this was an NHS app. The app logo is coloured stripes – which become obvious when you look at the app – it’s another one of the “ where do I go for what” apps”. 

Northumbria Healthcare’s GP Clinical Information Exchange

OK, so this is something different. Also has CiiX on the app logo. Says it gives real-time infomration about services, clinics and consultants  Not sure what it means by real-time, but what I like is it moves beyond being an directory to adding in some information about what to do if certain thing happen – and that’s good. I’m just not sure we need to add another acronym to the business.

NHSSC Health & Safety Awareness

Logo alert here, if only for adding SC to the NHS. It’s South Central (will need to update (or delete) app when the structural shifts happen). Seem to be aimed at staff though not entirely clear. I like the content but the title, logo and framing is poor.

Will Improvement be the new Nokia? An open letter to NHS Improvement Leaders

An Open Letter for NHS Improvement Leaders

Look around you - how many people are using a Nokia phone?

My first mobile phone, in the 1990's, was a Nokia. I wish I'd kept it as it sells on eBay now for more than it cost at the time. However, it's now perceived as an art form, not as a workable option for making phone calls.The demands on mobile technology have also moved on - I use my smartphone less for making calls and more for reading email and playing Bejewelled.

What happened is the context changed. The markets developed, the customers upped their expectations. Nokia, very successful in the early days of mobile technology got comfortable with their success. They became blind to the shifts and the need to dump their favourite (and no doubt hotly promoted in-house) technologies.

The basic concepts of mobile technology has not changed much - but the products have changed significantly.

The basic concepts of what we understand as quality improvement have not changed much since the days of Deming - what hasn't developed much are the products to implement change. TQM has been rebadged, with minor modifications into Lean, which has been rebadged, again with minor mods into a variety of corporate improvement programs. And so on.

Now, I'm not suggesting we throw out all the good things we know about improvement (I can't bring myself to call it improvement science" - it isn't a science.)  We can keep the basic concepts. However, I do feel strongly that retaining "legacy products and programs" is lazy. If you feel the need to say "we need to retain what works" then think through how that sounds to NHS staff - and what it reminds you of.*

Every improvement product designed in and for the NHS has been a consequence of the context within which it was designed, then implemented. The NHS is making enormous changes  both structurally, conceptually and clinically.  Retaining "legacies" doesn't feel like support to this new context.

Be brave, NHS Improvers. Match the pace and scale of the changes in the NHS around you. Let go of your outdated models, methods, tools and products, in just the same way as thousands of NHS staff are having to do on a daily basis for the practises they believe are useful and good.. Design for the future.  Practise what you preach and get innovative - from within.  And I mean truly innovative. I don't mean coming up with an edited version an existing product, or a new framework for something. Instead, create the breakthrough applications that not only fit in the current context, but reset the whole discipline of "improvement" in healthcare. The NHS has an enormous amount of improvement experience and brainpower - use this to good effect.

Nokia missed the boat. It's trying to turn around, but playing catch up in a fast developing market is far more difficult than leading the market by designing the market - think Apple.

In April 2013 the NHS boat will sail. New structures will be in place, along with new demands that will change the face of the NHS for both staff and patients.  My hope is for "improvement" to be on the same boat, and not one of the tugs pulling in the opposite direction.


Note: * Improvers often talk about wanting others to adopt new practises and when these people don't want to, they're labelled as "resistant to change". I'm just saying...