Future Fit healthcare remodelling in Shropshire…we’re not finished yet.
Here’s my attempt to unravel the tangle we’re in. Being no angel, I can risk treading in this thrashing pool of frustration.
I have just finished reading Matthew Syed’s brilliant book, Black Box Thinking. It has helped me bring into focus thoughts that have been in my mind for some time. So credit where it’s due.
Three years ago our healthcare leaders in Shropshire and Telford and Wrekin launched what they called a “call to action” to remodel the way healthcare is provided here. Three years later that action has not yet happened…not even started. It’s still a plan that has been rejected by different parts of the community, professional, political and lay.
What Syed writes about is fundamentally the unwillingness of people to accept that what they said was right, or what they did, was, or may have been, wrong. Even when evidence proves them wrong. They find reasons why the evidence against their case is not sufficient, or is irrelevant. They will reinterpret what has happened.
One key reason is that in a culture where mistakes are criticised and people blamed, to make a mistake is to face blame.
Another is that if those making decisions…or giving us medical care, or flying our airplanes…are seen to be wrong they fear we will not trust them. They will lose credibility.
Thus, there are numerous examples of organisations that have made a particular choice, for the best of reasons (in their view), that have been reluctant to change their decision in the light of evidence and challenge. These organisations usually fail. They press on with their plan even as they see contradictory evidence mount, because to change would be to admit they got it wrong.
They then attack the evidence that shows they’re wrong. It’s irrelevant. It’s flawed. We know better.
And they fail.
Well, Future Fit is now in this place.
Of course those leading the work believe their model is the right one. They have got their clinical evidence, and they have financial modelling. But they have not gone far enough.
Another essential element in Syed’s book is the need when designing a new model, device, factory, whatever, to test it to destruction. To test, redesign, retest, redesign…until it works. And you know it works. To reiterate time and time again, each iteration improving a little on the previous.
James Dyson did this over 5,000 times when first designing the cyclone vacuum cleaner. Those who stop redesigning too soon fail because their product contains flaws. And customers will soon stop buying the product with flaws.
Syed also said that asking experts…mathematicians for example…to solve a problem does not always find the best solution. A theoretical solution based on known theory and evidence does not allow for the infinite variables in any given situation, so again design, test, redesign is necessary. And don’t leave it only to experts.
(I hate saying this in view of recent political statements…)
How is this relevant to Future Fit?
The current preferred solution is to locate an Emergency Department (ED) in Shrewsbury, with most planned care in Telford.
The capital cost of the preferred model is around £311m. The SATH chief executive has recently said this is affordable. But there have been clear statements from government and NHS England that capital for the NHS is greatly restricted. The pot is being raided to replace reduced revenue funding elsewhere. Equally, the latest news is that capital will be prioritised for Trusts that meet (or better) their control targets, i.e. the deficits agreed a few months ago for 2016/17. SATH will not meet its control target; it is running a much larger deficit.
Around the country, the Sustainability and Transformation Plans (STPs) are being based on huge capital requirements for remodelling assets. And they are being told no. Why is Shropshire different?
The preferred model for Future Fit is not supported across the geographical patch. Politicians support ED in their patch, but not in others’. So MPs are vocally supportive as long as they get ED (and votes), but shout foul if they don’t.
The model is said to have been developed by clinicians. But it has been rejected by clinicians…the GPs in Telford…on the grounds that moving ED and the Women and Children’s unit to Shrewsbury will not meet the clinical needs of the Telford community.
The model is predicated on shifting a significant proportion of medical care into the community, out of acute hospitals. The shift can only happen if community and primary capacity and skills are significantly increased. But the model for this shift has not been worked out. So how can we know it will be possible? Our GPs do not like the Future Fit model precisely because they have no capacity for increased workload. Our Community Trust is bailing out and looking to be taken over, because they do not have the funds or capacity to continue what they do now, let alone expand.
The financial modelling in the Future Fit plan demonstrates that the capital outlay of £311m will bring more than proportionate revenue savings, even after paying back the dividend each year to the government. However, these financial assumptions have been called heroic. They are predicated on huge cost improvement plans (CIPs) that have been achieved by very fewTrusts in recent years. The likelihood of these savings coming to fruition is very low.
So we have a preferred model which is not supported by all clinicians, not supported by all politicians, which is based on very flimsy financial forecasts, and which is dependent on community and primary care that does not have the capacity to deliver it.
Why are we where we are?
I believe that Syed’s analysis helps us understand.
The model has not been sufficiently tested, iterated.
We have not been sufficiently creative and challenging in evolving the model.
Evidence has been used selectively to support secondary clinicians’ and financial experts’ opinions.
Syed describes a process whereby a team would be told that their plan had failed, before it had been started. The team then has to provide reasons why it failed. In this way the flaws in the plan are exposed in time to be adjusted before it is put into action. And the process works.
I doubt this has been tried here. Because even sitting here I can come up with numerous reasons why this plan will fail.
The core reason why iteration has been stopped, and the plan put forward as “must do”, is that leaders involved cannot face that the model is wrong. They say, no change is not an option. They say, we have to do this now.
But it is self evident that the model is wrong because it has been rejected. And to fly on in the face of being told it’s wrong is to, well, crash the plane.
The worst thing now would be to implement a model which appears to provide a solution but which will crash within years because vital elements cannot be delivered.
Those people involved in the project, if they read this, will probably dismiss me as a non-expert. They will say the evidence supports their model.
I’m saying, let’s test it to destruction now, before it is started. Let’s bring in more ideas. Let’s bring challenge. And let’s listen, reiterate, test, reiterate, and test again, till we all agree.
Let’s put aside professional egos. Let’s welcome failure as the way to learn.
Let’s be robust. Let’s not pretend that guesstimates designed to fit the model are reliable or credible. They’re not. They’re creating “evidence” to fit a model.
It may have taken three years to get here, and of course there is real urgency to reform healthcare here, but the worst thing would be to start something which will crash. At a future enquiry the leaders would justify what they did, but they still would have failed.
One reason for it taking three years is that the Future Fit “team” has been at pains to consult over many aspects of the model, before the model was developed and before the evidence was “created” to allow informed debate. Another is the two year creation of the “evidence base” to support their model.
They’ve been desperate to appear to be reasonable and evidence based, but they have been selective. Early on, clinicians decided what they wanted, and then “experts” were sent away to create the evidence to fit this model. Now they cannot face climb down. They have created a position where they are bound to fail because they have shut out other possibilities and challenge, and they have not tested their model to destruction.
Let’s avoid a plane crash. Delay take off, review, reiterate, wait for a better plan that demonstrably will work.