Review of a diabetes Locally Enhanced Service which identified the cost-benefit of the LES and worked with GPs to improve this.
. Some GP practices had sent GPs on the Warwick Diabetes Type 2 annual assessment course, and of these a number signed patients up to the LES. We analysed patient attendance at hospital for annual assessments, and compared this with the prevalence of diabetes by GP practice (trained GPs are more likely to diagnose diabetes at an early stage, resulting in earlier treatment, and probably less deterioration, higher likelihood of self management and greater quality of life though the time limits of this study did not permit us to explore this).
Although the difference in attendance was significant, it was not as great as the numbers of patients registered for the LES. We went back to the GPs to discuss this, convinced that patients were attending the GP for annual assessment, then naturally enough also attending the hospital for another annual assessment when the hospital sent an invitation.
GPs were very enthusiastic and helpful. Not only did they accept a lower LES payment (saying that much of the work was already covered in an existing LTC LES), they also agreed to discuss the issue with patients and so cause the behavioural change. Unfortunately I was unable to follow up this change due to NHS reconfiguration.

Community Matrons were asked to report on activity levels as a way of justifying their costs, but they wanted a more outcomes-based way of reporting. We developed a balanced scorecard aligned to the employing provider organisation and commissioning organisation’s own key priorities.

 I like to research thoroughly before responding to a tender, and a requirement came up that really challenged me. The client wants to know if their response to domestic violence represents value for money.  It's still early days for the service, but how it develops from here depends on the findings of the cost-effectiveness study, so we owe a really important duty of care for such a critical service.
For example: Which interventions work in reducing or preventing domestic violence? Is it enough to give women a place of safety, or does this just

leave the predatory man to go and find another victim? Will it work to lock the man up, or does that just pass the problem down the line? What about the debate raging in USA whether men really do commit more domestic violence than women, or the other way around?
The research took me in two directions:
·         What is domestic violence, and how prevalent is it?
·         What will cause people to change their behaviour?
I’ll look at the second in another posting,

What is Domestic Violence?
There are various definitions, and international agreement either on the words used or their definition is a long way off.
USA
In USA, Domestic Violence (DV) has been documented and studied for around 50 years[1], and USA has been running National Family Violence surveys since 1975[2] sparked a long-running debate about the gender differences in DV. This is important because any form of violence or psychological abuse can have direct victims and indirect victims (observers, unwilling accessories, for example children of the relationship and/or associated with either partner). The direct victims may seek healthcare, protection and social care. The indirect victims may also seek public support services and may progress to become abusers (or campaigners against abuse) themselves.
UK
BCS-IPV survey 2001 (the confidential supplement) indicates around 517,000 women suffer from some form of domestic violence (by the UK definition) every year. The BCS surveys people aged 16-59, and within this group there are 15.8million women, giving an estimate of 3.3% of women (1 in 30) affected within the last 12 months
1              intimate terrorism: what we would conventionally understand as ‘wife battering’ , the systematic coercive control of a partner by a variety of techniques usually in concert. Physical violence directed at the victim was probably a rare outcome in this type of DV but would be an ever-present threat and may be reinforced by acts of violence on the fabric of the house, furniture and pets/ children. This type of DV is probably the most damaging because its psychological impact would result in long-term repercussions. This is (according to Johnson) predominantly male on female in heterosexual relationships by a ratio of 9:1 (information on homosexual relationships has not been sought/ probably isn’t available)
2              violent resistance: in some cases (and not all) the battered wife (the vast bulk of Intimate Terrorism is man on woman) fights back, often planning for an opportunity when their assailant is less likely to fight back (eg when they are asleep) although sometimes they will try to fight back against a much stronger assailant anyway.
3              Situational couple violence: Johnson describes this as something completely different – when an argument gets out of control and one or both partners resort to physical action to make their point. He distinguishes it from the above because the violence is not part of a pattern of coercion techniques, even if the violence is frequent. Many of the examples of “husband battering” that are portrayed fall into this category
4              Mutual violent control: where both parties are using coercion to try to control the other. Johnson says it is rare and little understood. I couldn’t disagree.
Man on Woman or Both Sexes to Blame?
This could explain the feminist movement’s assertion that DV is man on woman, and the national survey’s results showing a more even distribution of violence.
The feminist movement studies on DV use information from women in shelter, in emergency rooms or seeking protection from their partner. Some will be escaping a strong and violent partner where the arguments get out of hand, but many will be terrorised and subject to a whole battery of coercion techniques. The bias in the sampling is acknowledged.
The national survey asks for self-reported outcomes. Johnson asserts that both perpetrators and victims of intimate terrorism will refuse to answer the survey, so the survey will only record situational couple violence.
It should be added that these types of violence are different (the one – losing control; the other – enforcing more control) and are likely to need different responses, for example violence from losing control is likely to be responsive to the price of alcohol·         Non-sexual violence including mild (slaps, holding down, punches, kicks), severe (choking or strangling, using a weapon), homicide, abuse, shouting and threats of violence
·         Non-penetrative sexual abuse
·         Penetrative sexual abuse (rape under the 2003 revised definition) including failed rape
Clearly whether they involve an intimate partner and/or are domestic depends on the circumstances, but it’s valuable to note that whilst non-sexual violence and sexual abuse are predominantly outside the home, by strangers, and are likely to be reported to police, rape is overwhelmingly (85%) by a person known to the abuser (54% intimate partner or ex intimate partner) and is likely to be under-reported by an estimated 7 times·         Dependent intimate terrorists
·         Antisocial intimate terrorists
Dependents can be characterised because their motivation is not to lose the partner and family. Their method is to control, and threats and violence form a part of that control, but they may recognise that they have a problem and seek help, for example from one of the perpetrator programmes (there are only two at time of writing, on opposite sides of the world, so select the nearest one

[1] First citation in Johnson’s 2008 “Typography” is to Snell et al 1964 “The Wifebeater’s Wife”(see  [2] “the Battered Husband” by Suzanne Steinmetz)

 Easington in County Durham is a COPD hotspot. It is a former mining community with a large proportion of elderly people and smokers. the prevalence of the disease is 2.8% - twice the national average - and COPD is the second most common cause of hospital admission. Easington PBC cluster looked at unplanned care and identified COPD; we tackled the improvements in stages, starting with the exacerbations the patients experience. New care pathways have been developed for patients experiencing an exacerbation at home which they are now able to self manage, and for patients experiencing an exacerbation where the referring clinician can refer them for a combination of home management and rehabilitation. Patients like the new pathways and the empowerment they get, and they like being able to stay in their own homes with their friends and family nearby, rather than travelling to hospital. This project won the Partnership award from National Association of Primary Care in 2008 (awarded in December) and also won the overall NAPC award for 2008. Links to articles in the press can be found below

See also www.shinwellmedicalgroup.co.uk for Mr Joseph Chandy

A PCT requested myself and a colleague to run a programme to redesign the process of booking patients in for community services eg long-term conditions management (it covered all services delivered in PCT buildings). Involving staff, stakeholders and service users revealed that the overall community service could be run more cost-effectively, and more appropriately for service users at the same time supporting healthcare staff, by devolving administration to the community buildings rather than centralising. The PCT was extremely pleased with the result.

Rosabeth Moss Kanter is a greater person than I, and has greater insights.  Therefore I'm going to quote verbatim:
1) Strong sense of purpose and value: “If you want to change the world, you better have a strong sense of purpose and value at the heart of your enterprise,” Kanter says. Many Fortune 500 companies are heeding this call — for example, Proctor & Gamble is committed to improving the planet through “purpose-inspired growth.” Pepsico “wants to make itself a healthy company.”
The Minney.org approach is to engage all staff in the objectives of the organisation and the community - whether it's "better health" or "life in the years" - so that each person feels a personal commitment, each team takes actions that contribute, and departments and directorates work together and support each other.
2) Innovation of a very imaginative kind: Kanter urged companies to move from “thinking outside the box” to “thinking outside the building” — to “look far out into the community, into the world” for new ideas.
As Einstein is credited with saying: "if you always do what you've always done, you'll always get what you always got."
We don't use "ice breakers" and "innovative thinking" for their own sake - we identify clear objectives.  If a workshop is supposed to generate new care pathways, then why have an ice-breaker that gets people to feel comfortable (and so satisfied with the status quo)?  Before you decide Six Thinking Hats is the tool, decide what the outcome is.  We'll support you to get real solutions, not just a feel-good buzz.
3) Partnering: Super corps develop and nurture strong partnerships with customers, suppliers, and communities. “We can’t do anything of importance in the world without a network of partners.”
We encourage the opposite of the building of little empires - collaboration and using each others' skills.  Years ago, preparing a business case and ongoing benefits reporting for community matrons, I had to fight them off from applying for their own finance clerk.  What they needed (and now recognise) is a friend within the Finance department who does the calculations for them.  Now, when the Chief Exec turns to the Finance Director and says "would you have a look at these figures?  Are they correct?" the response is "my team worked them out".  This applies to clinical review, workforce, facilities, working with the community, commercial partnerships, everything.
4) Self-integrating: People in organizations form their own informal networks. An organization dedicated to improving society will spur innovation and inspiration, thus “networks will be held together in a common purpose.”
See our response to point 1.  If people understand their purpose, they will form powerful and self-healing networks to contribute to their purpose.  They will survive changes of personnel, obstacles, flexibility, changing high level objectives, all sorts.  How do I know? because I've seen it done badly and I've supported it to be done well

If we’d known the start point, we wouldn’t have ended up here!

A tricky situation

A few years ago, my team and I were asked into a major teaching hospital to ‘run service improvement workshops’ in three directorates. They were at very different stages of development. One directorate ran seminars every year, and enjoyed brainstorming their possibilities, selecting the best options, working up action plans and benefit reporting, and assigning the tasks. Talk in the room was about opportunity and possibility, and how much had been achieved from previous years. One directorate failed to set a date for the workshops. The senior clinician was acting medical director and never had time to call his top team together, and the top team didn’t want to make a decision without him. Our best efforts to get them to talk about opportunities were met with talk of targets and indicators that they had to meet now. The third was different. On the surface all seemed normal – fairly high levels of sick leave and busy shifts that nobody wanted to work; give and take and banter.

Preparation is the key

As we interviewed each of the senior team in private, in preparation for the workshop, it became apparent to us that they weren’t on speaking terms with each other beyond the minimum required to keep up the façade. To try to run a service improvement workshop with this lot would be to try to teach a hungry tiger how to perform first aid – the end might be worthy but they just weren’t ready for it.

A disaster waiting to happen – averted by careful planning

In our case, we spotted the situation and were able to change the nature of the workshops so they became much more personal, directly tackling the communication issues and the very real resentment. We got the 6 top team members to discuss (in a protected environment) how working in that situation made them feel, what they thought could be done to put it right, and their own personal responsibility for both the problem and the solution. With the top team united, many of the problems of sickness and understaffed shifts resolved themselves with substantial improvements in patient safety and patient experience.

Cost-Benefit Analysis

The key is to use facilitators who are skilled and experienced enough to identify the situation they face, and to prepare a plan to resolve it. Can you imagine the ‘successful’ workshop that failed to address the real issue, and that perhaps resulted in humiliation for senior staff with the inevitable litigation and claims for unfair dismissal. I often meet people with the title “service improvement facilitator”, and there’s an enormously wide range of skills and experience. Some have 20 years’ of managing teams and delivering workshops, whereas others are just out of training grades (“no experience needed”). It will pay for itself many times over to get the right outside organisation to tackle those difficult situations, and give your staff facilitators a chance to learn from example.