Dr Chandy cares for people with a variety of extremely common conditions: tiredness, depression, weakness, indigestion, in ways that some think are controversial.  The video is below but find out more at http://b12d.net/content/bbc_documentary_and_testimonials

You can also find out about the GP surgery where Dr Chandy is principal GP on http://www.shinwellmedicalgroup.co.uk

How to improve outcomes, how to be more effective?
The Darzi reforms had their first anniversary last week - and they have been very successful over the last year, certainly in terms of brand awareness.
Quality was the theme for the year. It was a good theme - highest quality removes waste which avoids unnecessary costs (more effective), and often quality and effectiveness go hand in hand.
There's only so far you can go with improving quality and improving efficiency. The same pathway but better. 10% cheaper. As the Wanless 2002 report indicated, if we're still doing health care in the same way in
20 years as we are today, every able person will be occupied looking after the
less able - we have to change
Innovation
Making a real difference comes from being prepared to start again, to go back to the drawing board. All the lessons we learnt about process mapping, about redesign with patients and front-line staff, are all appropriate here: perhaps one of the classic examples is the ECP, giving the first professional contact with the patient, the skills, competencies and authority to change the care, to refer to a more appropriate patient pathway. This makes a real difference - community care instead of hospital care, self management instead of institution.
Permission to fail
But how do you know when it's working? That's when a really strong measurement and reporting regime is needed, tied to meaningful measures designed and implemented by front-line staff, permitting staff to recognise where their own project works and where it needs modification, and the tools to make the changes themselves.
Communication
Of course it requires people to talk to each other. In a market place environment, commissioners and providers need to understand the risks and rewards of innovation and work together to achieve the much-needed benefits

All of the above projects were run by Hugo Minney and I'd be delighted to work with you on your project

Reference
'Securing our future health: taking a long-term view' April 2002, HM Treasury an independent review by Derek Wanless
Search for: INNOVATION

Is the Secretary of State for Health falling into the same trap that a Blairite minister did, of announcing the outcome before the listening exercise is complete?

The Rt Hon Andrew Lansley says he "won't accept any changes" unless they are good for the nation.  But the whole point of the listening exercise is to understand what is good for the nation, and quite frankly, perhaps the new health legislation is wrong in principle, even if some bits of the detail are right.

So let's have a look at it:

RIGHT

Doctors should decide what is best for the patient, and have the freedom to act on it

Doctors should understand the costs of the health service, and propose alternative pathways which both benefit patients and make best use of resources

Patients should have a choice of provider, which will improve patient experience as the money follows the patient

WRONG

Competition isn't intrinsically good.  If you don't set constantly improving standards, or don't monitor them, or don't have the teeth to act when someone falls short, then quality of clinical outcomes will fall just as fast as the hotel services to make the patient feel good improve

A health regulator needs to have one sole purpose - ensuring quality healthcare for the present and the future.  This means financial probity as well as clinical standards.  It does not mean distractions such as encouraging Competition or Cooperation (if they raise standards then they will evolve naturally, if they won't raise standards then they have no place)

It shouldn't speak with forked tongue.  Either the Doctors are in charge, or the Secretary of State for Health is micro-managing.  On present evidence, the Secretary of State and Department of Health can't help themselves and have to interfere with the fine detail of the health service.

GPs aren't accountable to the local population.  They are businesses and they stand or fall on their money management.  If you want health services to be accountable to the local population, then ask local authorities to do the commissioning! Leave the decisions on individual patients to the Doctors, and decisions on the marketplace to the Local Authority (no, PCTs weren't accountable to the local population either - it's difficult to say who they were accountable to).

GP consortia are too small to negotiate with Hospitals.  We're going back to the situation we were in in 2004, when hospitals had all of the information and all of the activity, and simply said to PCTs "this is what we're offering, take it or leave it".  Again, about the only organisations with the financial and legal muscle to enforce quality standards and information reporting are local authorities.

Start again

So don't cling to a bill just because it has your name on it.  Listen to your listening exercise.  Be prepared to do what is right for the country!  Be the first!

In the run-up to the general election, all the political parties trying to win your vote using the NHS card. They make all these wild promises, but what is going on behind the scenes?
Labour -- Gordon Brown's health team is promising something for everyone:  the public can have whatever they want – if they drink themselves nearly to death the NHS will put them right; speaking of rights, they will have the right to be waited on hand and foot. The NHS will find £20 billion worth of savings. And any manager who cuts services will be named and shamed.
Conservatives -- David Cameron promises a better NHS. His health team is busy flirting with private companies, to great effect (Andrew Lansley’s electioneering pot is £20,000 richer!). The United States experience of private healthcare is that 40% of all spend goes on administration. This means; 40% less money available for patient care -- how can they maintain standards of patient care if the money is being used up on administration?
Liberal Democrats -- lots of worthy talk, very little sign of realism and implementation – but then they don’t think they will actually have to do anything.
BNP – apart from wanting to paint everyone white and sterilise anyone who isn’t a member of the party, I haven’t read anything interesting yet.
But what do we gain from all of this navel gazing?
It's as well to be prepared. If an incoming government is going to do what's necessary, that is, empower the people and organisations who can have the most impact, then those very same people need to be ready with ideas of what to do and plans to do it.
If, on the other hand, an incoming government plans to continue the current policy of promising everything and funding nothing, then we -- the people who can make a difference -- need to reconcile ourselves and continue doing the best we can.

I've worked a long time understanding health in UK - on the outside looking in (selling into the health service and NHS); I worked at a national level developing and supporting policy; I've worked regionally, implementing policy and strategy; I've worked in NHS organisations; and I work in a GP practice at the moment. The biggest difference that can be made is where the patient first touches the health service. Most of the time, nine times out of 10, that's with the GP.

The right resources in the right hands
GPs make the first decision following a diagnosis: they can make the biggest difference to the quality of service the patient receives (by referring to the best pathways), and the amount of resources (cost) that a patient consumes (by using appropriate healthcare close to the patient's home). It really does make sense to empower the GPs and support them to care for their patients.
So how can primary care trusts engage with their GPs?
The first thing to do is to listen; understand the concerns they raise; understand their ability to implement (or inability); and understand whether they are looking for more money for themselves, or more money to support their patients.
It's important not to get precious. If someone comes up with a good idea for a service, that doesn't mean that you'd steal the idea and give it to your PCT provider arm. NHS as preferred provider was old-fashioned before Andy Burnham said it – competition has created some inefficiencies, but it has also created an enormous amount of good.
Making it happen
Minney.org Ltd works with many health and social care service providers and commissioners: we promote engagement, we are realistic about the provider's ability to implement the good ideas they come forward with, and we support Commissioners to get the best for their population. It would be pleased to talk to you about what we can do for you. Contact me on the contact details below.
 

We need to consider what we, as organisations and individuals, can do to reduce our own carbon footprints. It’s all very well to talk about it, but this winter, this extreme weather, shows just how close global warming could be. For Britain, global warming doesn’t mean getting warmer, it means getting colder – we’re on the same latitude as Alaska, and we should expect that sort of weather.
The talks in Copenhagen didn’t seem to be about us – they seemed to be about the way nations handle it. But macro-economics is about influencing what many individual people and organisations do, and that means that talks in Copenhagen were about to you and me, and our individual actions.
So what is this to you and me? I know I, for one, take the train whenever I can. I walk to the railway station, just over a mile, even when it’s wet, or cold, or dark, or snowy as it has been in the last few weeks. I don’t feel smug about it, in fact I am almost frightened, because the weather seems to be a little bit freaky.
What action can you take?
People receiving care in hospital reduces the number of carbon miles that your staff run up to give health care. But what about the carbon miles that patients run up coming to hospital, either for treatment, or to visit their friends and relatives? What about the costs of heating and lighting a hospital, when the patient’s own home is going to be heated and lit anyway?
Perhaps it’s time to look again, with fresh eyes, and what can be moved into the community. To look at what GPs can commission, and even what GP provider organisations can provide.
The results could be outstanding! Not only could you reach your targets for moving Healthcare out of hospital and into the community, you could also hit your financial targets at a time of constraint, spreading your finite budget to care for more people with more conditions. What are you in Healthcare for? This has to make sense!
 

So Scottish MP's are concerned we will lose an ancient Scottish tradition? Alcohol unit pricing at 40p per unit only hurts those who buy very cheap alcohol, the people who buy alcohol to get drunk. The tradition that MPs get misty eyed about is the Scottish whisky industry, and I for one, have never heard of whisky at less than 40p/ unit.
People are dying out there. Yes, we of the society have become rich enough to kill ourselves, and unfortunately, the nanny state leads us to believe that we can do whatever we like because the Health Service will put it all right again.
So MPs. are being asked to consider a minimum price on cheap alcohol. What's not to like?
Dare I say it, the funds the run their election campaigns? Or is it even more sinister than that? This isn't about taking away freedoms, this is about preserving life.
Come on you wimps, stand up for what is right for once. And let us hope that this minimum pricing also applies in the House of Commons bar.
 

So what is Christian about Christmas? The date? By all accounts Jesus was born sometime in March not December. The decorations and festivities? Far more likely to be connected with the Roman feast of saturnalia. In this feast, women dressed up as men, saved as masters, and in the British versions (Lord of Unrule, and Abbott of Unreason), the law courts were closed for 20 days which meant that any law breaking would go unpunished.
How about the candles? Lights in the middle of winter come from a pagan ceremony, and aren’t Christian at all.
The This is probably the most Christian thing about Christmas. You might expect an evergreen tree was a pagan symbol of worship. Actually pagans often worship oak trees, and some saint or other, chopping down oak trees to stop them being worshipped, discovered a fir three amongst the roots of one. It was fitting, new life out of old. Evergreen eternal life.
How about Santa Claus? There’s a popular giver of gifts. It’s usually depicted as an old woman. Santa Claus, or Saint Nicholas, rejoices in a story that he gave money to three sisters who wanted dowries to get married. There’s no mention of children here, or even that he was particularly religious - just a childless old widower with a kind heart. In fact pre- Victorian times, Santa Claus could appear in many different colours of outfit, and was usually much thinner. The chubby Santa we see today was created by Coca-Cola in 1931. Santa has been used to advertise cigarettes and booze for most of the last century.
Is this Bah humbug? I enjoy my Christmas as much as anyone else. I’d just like to know the truth.
 

We’re introduced to the world of Brazilian politics and industrial relations, conglomerate in the middle of a recession, and in a working environment where employees are suspicious of being exploited by employers, and employers can’t make an income because of Byzantine laws and checks which can only be passed by crossing many palms with silver. It’s half a world away, and nothing like our own dear public services.
In walks Semler Jnr, with his USA M.B.A. degree and lofty ideals, and inherits his father’s industrial conglomerate. 

 A lesser man would have bowed to the pressure to conform: so set rules and performance manage, to centralise and strip out costs, to look for loopholes in the law and pay off government officials. Remember this is no Silicon Valley dream of 100 motivated employees – even when Semler Jnr inherited there were thousands of employees with history.
Ricardo takes the road less travelled. He removes the executives that served his father, the old way of doing things. He teaches his workers little by little (“choose what colour you would like the wall of your workplace” then “decide for yourselves what changes you would like to make – I as managing director am only one vote on your governing council” then “the accounts are open for all to read, and we even give you lessons in understanding accounts” finally to “set your own wage rates and the wages of the executives at the top of the tree”). It took him years, but he now travels the world telling others of the economic miracle that grew out of such a harsh crucible.
Of course it is nothing like NHS. We don’t have Byzantine rules. We have innovative directors and executives, always looking for ways to improve staff relationships and do things better. We don’t have rules, only an empowering environment in which every person can excel. Healthcare is nothing like manufacturing, every patient needs a unique approach. We have nothing to learn from this book.

How can I even say this in the same breath?

Simple: some management consultants are very cost-effective:

How expensive are salaried staff?

Your employees need: holidays, training, sick leave, compassionate leave, pensions, NI, administration, appraisals. All of this adds up to around 2.4* the original cost of their salary, in other words whereas your front-line workforce might cost £1,000,000, your wages costs including the HR department, management etc will be more like £2,400,000.

So, coming back to your employee on £20,000 per year. Assuming 215 productive days, this is £93 per day. So you would expect the management consultant equivalent to cost £223 per day just to be the same cost to you (because management consultants have to look after their own pensions, NI, tax etc and don’t need layers of appraisals).

Your employees have specialist skills and work very hard. But they have to keep up with developments (reading time, study time), and they have to do many different tasks – very few organisations for example have a requirement for a full-time Benefits Manager. So you may get 215 productive days per year, but of these, 20% are spent on reading time, there are times in the year when there isn’t much to do but you have to go on paying them, there are even times when you create tasks to keep people occupied. The rough average is that 40% of the time, productive staff are doing the tasks required.

If you worked out how much it costs to keep your own employee, per day spent doing tasks which support the future success of the company, suddenly £223 per day becomes £557 per day. Of course I’m not talking about task-oriented staff, who do what they are told and are productive the vast bulk of the time; I’m talking about people who plan, who do specialist tasks, who engage with others.

Remember, that £557 per day is for the equivalent of an employee on a £20,000 salary. Is this the level of skill you actually want?

What level of skill do you want?

So if you want a senior manager level (£50,000 salary) for a specific task, and only expect to pay for the days worked, and of course expect the senior person to remain fully trained and up-to-date, only in their own time, then you would pay 50/20(salary multiple) * £557 per day = £1390 per effective day if you had them on payroll. You will typically get this level of person as a consultant for closer to £650 per day, a veritable bargain!

Making savings

So you want to make savings. The ONLY way to make savings is to use fewer people. But if the staff you currently have are working hard, then you have to:

Stop doing some things (usually what doesn’t need doing and perhaps never needed doing)

Do other things more efficiently (a variation on the above – often you drive efficiencies by removing steps that simply don’t need doing)

Do new things that mean that you won’t need to do some time and resource-consuming activities (this often applies in Health – taking time to help people stop smoking will pay dividends when there are fewer people with 20 years’ smoking-related diseases)

It’s difficult to see new ways of doing things or even to accept that some things don’t need doing – that’s often why organisations bring in management consultants – to look at the job with fresh eyes. 

However these “strategic” management reports that make sweeping “save £20 billion” statements have often not looked at the detail; they are often little more than company brochures with the clear message “put lots more work our way and we’ll be very pleased”.

Government “savings”

Actually often the requirement isn’t to save money, it’s to do more with the same resources. Take NHS – we expect around 7% more need by 4 years’ time. So we’ve been asked to make £20bn savings over four years, which equates to around 7% savings over the same period. This doesn’t mean this money goes out of the health service, it means that we need to do more work with the same resource.

In other words, same numbers (or similar, at least) of staff, but each more effective.

Spending their time 7% more effectively

Doing fewer of the things that don’t need doing (and one estimate is that at any one time 30% of the things we do are no longer relevant given current understanding and technology/ medicine)

Doing the things we do, better (more time with patients, less time travelling between patients; more time face to face, with the clinical notes available via IT and updating the clinical notes made simpler and easier)

Doing pro-active things, like see and treat, first responder, instead of referring people to hospital to see someone who says “that’s fine”

We have a challenge right now to invest in making these changes. Remember NHS is not about innovation, it’s about delivering a service 24 hours per day, 7 days per week, 365 ¼ days per year (don’t forget the last ¼ day!) with innovation ONLY where it is safe to introduce.

Terrorism is about money and power. Take, for example, Taliban suicide bombers. If martyrdom is such a quick way to paradise, why haven’t the generals used it to get to paradise themselves? I weep for the poor cannon fodder who get brainwashed into losing their lives so hopelessly, just as I weep for the victims both public and military. But the issue is really about money, the money the generals want, and not about religion.  As usual, that is just an excuse.

A few people in Afghanistan get rich from drugs – heroin in particular.  These are the warlords, with absolute power, the power of life and death over their serfs.  The international community wants to stop them getting rich, and they don’t want to be stopped. We'd have been in there and either stopped production or managed production of opioids for medicinal use.  The logical response by these warlords is to distract the international community with bombings, acts of terrorism, pretty much anything that dilutes the amount of focus we can bring to bear on stopping the illegal drugs trade.
So why are we fighting this war in a far-away country?
Well I live in beautiful England. There are a few places where drug dealers push heroin on street corners, and a few more where it is possible to find heroin if you know where to look, but on the whole we’ve stopped it and I’m extremely grateful. If a drug dealer set up on my street, I would expect the enforcement agency (police, criminal justice system) to stop them. If it was the next town, the chances of drugs reaching my neighbours’ kids and of people desperate for the money for a fix breaking into my house are still high – I want it stopped. Afghanistan may be the other side of the world but that's still too close for comfort.
We are also at risk of terrorism. Lawlessness breeds lawlessness, and Britain’s open borders policy which has brought us so much good in the past continues to benefit us, but also leaves us open to potential terrorists finding their way into the soft underbelly of our great country. But we’re also at risk of a much more serious danger – widespread use of opiates that take away people’s will to strive for anything in life turning them into indolent dreamers, or worse into violent criminals desperate for the money to fund their habits.
I commend the brave soldiers who protect me, my family, my neighbours, my friends and colleagues, you readers.  I just wish the politicians and leaders were a little clearer about why we're in there and how we will know that we've done a good job - "winning" or "defeating the taliban" isn't good enough.

Senior Management and Director pay in public service seems to have gone up and up recently. Are we really attracting better talent, or is it a game of "who can have the most expensive Chief Exec"? Public Servants used to be motivated to serve the public. The rewards are (still) there - job security, first class training, holidays, hours, gold-plated pension, an honour from the queen. Salaries weren't quite as good as the private sector, but the overall package was probably about the same Attitudes are changing. But which came first? Did higher pay make people focus on money and forget service, or did people leave the Service in droves because pay wasn't good enough? There's a place for high pay - and it goes with high personal risk. We may make life and death decisions, but it isn't usually our own lives we're deciding about. I think it's only right that people take the rough with the smooth and show some real empathy with the suffering of the people we serve http://www.hsj.co.uk/news/workforce/civil-servant-pay-freeze-announced/5007034.article

The political parties are falling over themselves to say they will protect the health service budgets. But is this true? (http://www.hsj.co.uk/news/finance/andy-burnham-makes-no-promises-over-nhs-cuts/5006740.article)
Department of Health (DH) has asked SHAs and PCTs to identify £20bn of savings.
Lets examine £20bn. This is an enormous amount of money! It means a colossal shift from inpatient to outpatient, from hospital to community. It means real cuts in staff numbers. It means real cuts in the drugs budget, when UK already knows it has some of the cheapest medicines (as GPs and hospitals start selling them abroad to make a quick buck). Without massive involvement from GPs to change their referral patterns (and we've banked on this happening so many times before and failed to engage, what's different this time?), it means cuts in the quality of care. Could this be the push that will drive people from Care Free at the Point of Need to Basic Care Free, pay for everything else you use? I hope not, but then the rising cost of health and social care for an ageing society may simply not be a vote winner.

Where's the corporate memory?  Who knows what the organisation does, why it does it, and what it should do when the next challenge comes up?
 
Of course, the staff know.  But staff move on, and if the information isn't shared, then the information goes with them . . (most graphically shown in my Baseline Report on New Ways of Working where the information was difficult to find because so many people had moved on in the most recent reorganisation that 3000 projects representing 10s of 1000s of staff and £millions in investment was rudderless and reverting back to "the ways we used to do things").
So how can you capture that?
I wouldn't want to be treated by a doctor or nurse who had learnt everything from a book.   Why should I then accept that management will approach each situation anew, with no reference to what went before except what they got out of a book?
Knowledge Sharing
Some things can't be put into electronic pigeonholes, they have to be passed down from person to person.  The role of the knowledge manager is not to catch, kill and pin down the corporate memory, and then to guard it against all comers, but to network, to introduce people to each other, to encourage knowledge sharing where it isn't captured centrally. Does this make everyone a knowledge manager?  It certainly makes every leader one.
So to be efficient, how do you keep and share the knowledge?  If there is so much, how do you decide what's important and must be kept, and what you can afford to lose?
Reasons Why
Richard Barrett (who was knowledge manager at the World Bank) in his books "Liberating the Corporate Soul" and "Building a Values-Driven organisation" illustrates organisations which are held together not by knowledge of facts and figures, but by shared values.  If you know where you're going, then you will all pull in the same direction.
Perhaps this is the answer.  Today's solution to a problem is only marginally relevant to tomorrow's problem.  Today's reason, today's direction, today's values may be entirely pertinent.
Minney.org uses Barrett's principles (one of our associates is a trained Barrett consultant if you want the whole programme) to help the organisation understand where values align, where they don't, and to determine what can be done.
You'll identify the staff who fit and ensure they fit all the better.  You'll lose the staff who don't fit, but in the nicest possible way.  You'll probably get twice as much done with half the staff (well in a service organisation probably +20% with -10%) and develop a much better atmosphere.  And you won't worry about if you've captured every last bit of information, because teams can be trusted to deliver the right outcomes and don't need micromanagement of their outputs

The current benefits system is labyrinthine, and needs to be simplified[1]. But then, so is the tax system. Did I read somewhere that this year’s tax guide is twice as long as last year’s? In trying to make it fairer, we just make it more complicated. Whitehall mandarins create sustainable jobs (for themselves) but not a lot more.
The issues:

The rich should want to stay in Britain and pay taxes which contribute to society.
The poor should have enough left over that they can spend and prop up the economy.
The in-between should feel rich, consume, and generally help the commercial wheels to turn.
Those who need support from the state should receive it, no child should be brought up in poverty or deprivation, and all should have an equal chance.
There should be no barriers to taking a job, for example where the reduction in welfare is so fast that you are worse off if you take a job.
There should be little incentive to avoid or evade tax.

The Proposal
What about a flat rate of tax for everyone, from the first penny they earned, and a flat welfare payment to everyone, regardless of their wealth? The payment would be set both to meet the minimum needs of welfare for the poor, and to make up for the lack of a stepped income tax for the rich. So if you earn over £5400, then you would normally receive the first amount untaxed and only pay tax on anything over this. An alternative is to tax you on the lot, but pay you back an equivalent amount. So if you have dependents such as children, or people needing care who don’t have an income of their own, your welfare payment is adjusted accordingly. We get the same result with the current tax system, only it takes a lot more people a lot more effort to work out – and all the while these people aren’t contributing to the economy they are only marking and performance managing it. So you get enough in to live on. You take a job, and suddenly you are taxed 40p in the £. No decrease in the basic amount you live on, the remaining 60p in the £ goes straight into your pocket (or on travel, but there will be some left over). I don’t think people want to avoid paying tax, they are just aware of the impact that declaring an income will have on their welfare payments. Remove that dis-incentive and I think more people will pay tax.
There – very simple.
What happens to all the benefits staff and tax staff who currently operate the (much more complicated) system? They can do things that contribute to the economy, like service industries, manufacturing, creating wealth. Will they mind? I would hate to become aware, after 40 years in a job, that all I had achieved was to slow things down – I’d much rather look back on a contribution that I’d managed to make.
Reference

Dynamic Benefits: Towards Welfare That Works" A Policy Report by the CSJ Economic Dependency Working Group [16/09/2009] – centre for social justice

Sir Michael Bichard is a man to listen to – his proposals are practical and usually sufficiently well supported that they make it into policy. I was listening to him on Radio 4’s Today Programme this morning (Friday 18 Sept 2009) discussing Local Government with Tony Travers of LSE. The gist of the conversation seemed to be that local government has delivered significant innovation, whereas Whitehall had offered no improvement. But local government couldn’t go any further because they are micro-managed – their income is set by Whitehall, and services are also set by Whitehall. Sir Michael Bichard and Tony Travers stopped just short of saying that local government should have tax-raising powers – reduce the tax take of central government and give local government the freedom to raise tax and services, or reduce tax and services.
Would it work?
Yes probably, but it would be quite complicated. Residents would make up part of the local tax take, employers another part, and sales tax the last part. Residents would be relatively easy to define – if you live there you are a resident. But does a business have to split out the employees in each branch office, and pay tax accordingly? And what’s to stop them registering all employees at a tiny hut on Skye, when they actually work in London? What about retailers and the sales tax portion of the whole? How much paperwork would be needed for filing 150 tax returns in 150 locations?
How about the impact on democracy?
There’s a tendency amongst politicians and public servants to believe that business can go on and on paying, and in spite of some high profile moves out of UK, businesses are still seen as an easy target. If taxes were paid locally it would be easier for businesses to demand representation locally. Democracy happens where the people are. As Time magazine reported a few weeks back, “we send our representatives to Congress to do our work. When they get there they work for big business” – national and international government can’t see past their own navels and don’t represent us. More and more power should be local.
I’m all for local taxation
I’m certainly for local accountable government, with the ability to respond to the needs of the voters by raising more (or less) income to provide more (or less) service.

"Here comes Edward Bear now, down the stairs behind Christopher Robin. Bump! Bump! Bump! on the back of his head. It is, as far as he knows, the only way of coming down stairs. He is sure that there must be a better way, if only he could stop bumping for a moment to think of it.“[1]
 

How often are you so full of busy that you can’t think?
How difficult it is to make space though.
David Allen (author of Getting Things Done [2-3] ) recommends booking time out, a few days at a time and then a day every so often, to sort through the paperwork.  That’s a serious risk (imagine telling colleagues “I’m off to do my filing”?) and unless you are rigorous, I’m sure anybody like me would find it squeezed out by other priorities.
Ricardo Semler (Maverick [4] ) has a different technique.  His view of filing is that you only file what you know you will definitely need – contracts and so on. If something else is important, then someone else will have a copy!  Of course this only works if you are the only one who throws everything away – I often find I’m the only one with a copy left!
But that’s just trying to make space to get organised – what about time to think and be creative?
We’re told (and I’d love to know how “they” found out) that Richard Branson spends 5 minutes every hour with his eyes closed just “thinking”.  Peter Thompson recommends getting up an hour early in order to visualise the day (which allows plenty of time to be creative and even to imagine the scenarios you’d really like), and a number of people have said this works for them. Many corporate boards book “away days” to create strategies, and it certainly works in the corporate world.
I think the issue for Public Sector is much simpler than this – the key deliverable for the customer (population served) is often the 24-hour, 365-day services which are really pretty mundane.  So most attempts at taking time off for strategy and planning end up either discussing the mundane services [5] , which don’t really change, or being very self-indulgent and doing esoteric team-building-y things.
Being creative for the Public Good
When do your best ideas come to you?  In the bath?
When out running?  When you put aside time for it? The best ideas often turn up when you aren’t expecting them.  The most polished, most diplomatically acceptable, when you put aside time. This means creating space in every day to be able to capitalise on those ideas and turn them into something – not race in and tell your staff to “implement this brilliant idea I had” and then wonder why, a week later, they didn’t understand how brilliant it was and how well it would work, but actually implementing them yourself and nurturing them into existence.
References

Milne, A.A., Winnie the Pooh. 1926.
 

Allen, D., Making it all work : winning at the game of work and the business of life. 2008, New York: Viking. viii, 305 p.
 

Allen, D.D., Getting things done : the art of stress-free productivity. 2005, London: Piatkus. xiv, 267 p.
Semler, R., Maverick : the success story behind the world's most unusual workplace. 1993, New York, NY: Warner Books. 335 p.
 

Blunden, F., Frances Blunden on the burden of NHS bureaucracy, in Health Service Journal. 2009, HSJ.co.uk.

I met some old college friends over the weekend, and realised the contrast between those following their passion, and those who'd accidentally ended up where they were. It made me wonder "am I following my dream?"
I'm passionate about the benefits work I do because i believe that it can make a difference.
Taking a benefits approach, people become more outcome-focussed, not just on what it means for each person's own career (and this is important, and must be the biggest driver in any communications strategy), but on what it means jointly, for our peer group, for the people we care about, for the people we live amongst. As we become more outcome-focussed, we start to think about what we want to see - what will it look like when we have it.

There's that clip in "Field of Dreams" where Kevin Costner looks back at his farm (You Tube video), and sees the baseball pitch appear as if in a dream, where he should build it. Once he has the vision clearly in mind he knows what to do step by step, and perhaps more importantly, how to tell if he's making progress.

And this is the essence of the benefits approach - BEFORE the real and ultimate benefits start showing up, how do you know if you are on track or if you need to make an adjustment? When you see the ghosts of the players, are you imagining or visioning? That, essentially, is what Rapid Benefits Assessment and the Benefits Approach are all about.

‘Writing to inform and persuade’ is the knub of it; but who is to say what is good and what is bad?
Two presenters
I listened to two medical talks a couple of months ago. One followed all the rules: the slides were clear and memorable, forming a continuous story with a start, middle and end. The content was relevant to the audience; the talk ran to time.
The second stood between the delegates and dinner. It consisted of 40 slides for 20 minutes, each one another case study. Many of the slides were scans of handwritten notes and Word documents. With every slide, the presenter paused, looked at the slide, said “oh yes, now this is a very interesting one” and proceeded to spend 5 minutes describing it in detail.
At 20 minutes I interrupted and asked the audience if they were prepared to delay dinner to listen to more. They were fascinated at this old man, talking about his life’s work in this rambling way, and many committed to check their own patients for the same symptoms.
The younger doctor who gave the first presentation left in disgust.
My lesson
I wonder if we concentrate too much on form over function. PowerPoint slides “should be this”. Rules for doing a good presentation. Dressing for power. I don’t give talks unless I have something to say – content leads, followed closely by enthusiasm (if it doesn’t excite me, why should it excite anyone else?).
It makes me wonder how many times people try to whip up enthusiasm when they are only faking it. How many talks have no real content – they just fill a 20 minute, or 90 minute slot. How many times we say what we don’t mean. Action steps If you want people to buy more services from you, what’s the risk in saying so? Be clear: “this is what I’m enthusiastic about, this is the difference it can make to your work, now buy from me”. Audiences are cynical and suspect that’s what you are trying to say anyway, and telling them that they were right is surely one of the most sincere forms of flattery!
If you want to reignite that enthusiasm that people had when they joined, the passion for the work, aligned to your business objectives, that’s my specialist area. Talks, workshops, implementation; make it happen, make your organisation sing again.

Quality is the new buzzword (HSJ 25 June 2009). I return to my original thesis, that all care is delivered by people and therefore innovation, and quality, is predicated on the motivation of staff, volunteers and carers.

Measuring becomes ever more important than ever. "People do what you inspect" is just as relevant to the self (I do what I'm measuring - I take a shower faster if I'm timing myself, I stick to speed limits if I treat that as a priority) and staff that set their own goals and have the tools to understand how they fare compared to the goals they have set are going to achieve more, with more enthusiasm, faster, than a team with an imposed goal, and feedback 6 weeks after each monitoring period. Give people the tools to make a meaningful difference, and we'll do it! Hugo can establish - with front-line teams - frameworks for Benefits design, planning, realisation and reporting and help align individual and team goals to the strategic objectives of the organisation or local health (and care) economy)

Today at the supermarket we saw rather a lot of very smart convertible cars. Drop-top jaguars and mercedes, roaring porsche and TVR. I'm sure I read somewhere that there's a recession on. Isn't it interesting how the weather can reflect the times? Or do we just notice it when it does? The weather's unpredictable. The public appears (at least from the newspapers I read) to be completely split on who is best to run the country - do we go for the party that promises everything to everyone (in the same speech promising to "cut mindless burocracy" and "provide administrative support for frontline staff"; then promising to hold down public sector spend with reductions of 10% a year, but of course the [insert audience here] department will have its budgets maintained), or the party that everyone loves to hate but rather a lot of economists and bankers are saying other countries should immitate? The health service faces its own dichotomies. There are finite resources. There are new technologies, each more expensive than the last, each marginally better. People are definitely sicker - where did MS, ME, Fibromyalgia, CFS come from? Or did we just not diagnose them before? Why the sudden increase in diagnoses of depression, neuroses, autism? Is it really because we can diagnose them, is it really because we keep people alive who would otherwise have died, are there enough kept alive to account for these large increases? I wonder how many of these problems come back to simple things. Take the situation in the health service: could it be that something has changed about the food we eat? And could it be that unexplained presences or absences in the food are causing all of these problems? Makes you wonder if the same is the case for politics . . .

It's not enough to throw money at the problem. We need long-term commitment, planning and the intent to collaborate before we can ask care providers to risk their neck to introduce the innovation that is so vital for delivering care tailored to individuals, with quality outcomes, and in the quantity required.
Allan Bowman of SCIE (Social Care Institute for Excellence) points out that it’s not enough to throw money at the requirements to fund care for older people and those with a disability; we need to consider whether the capacity is there to deliver care at the right quality (reported in Guardian Public magazine [1]). Of course this doesn’t just apply to social care for these groups – it applies to all public services where the care will be provided by a mixture of public and independent providers (ie pretty much everything). Care is constantly evolving, getting better (whether this means more tailored to individual need, giving outcomes that meet a higher criterion of health and well being, more effective use of limited resources, or all three). However any change costs money – requires that pioneers develop the new enhanced service. The mantra at the moment is to learn lessons from overseas – but with USA trying to be like UK [2], and many other countries with no real concept of publicly funded health and social care, where will we learn these lessons? Public sector commissioners used to rely on charities for innovation. But charities are increasingly reliant on an income from the provision of specific services[3] and have less left over for testing out new types of working[4]. There’s a vital need to invest for innovation – the funds have been made available but without the security of a funding stream many organisations are simply unable to commit to building the capacity which will provide services of appropriate quality, and enough workforce to provide the capacity, We found [4] that the expectation is smaller organisations are more agile and likely to innovate, whereas they don’t have the capacity to deliver the volumes local authority requires. An ideal solution would be to contract with a consortium of suppliers required to collaborate, so some can focus on innovation and sharing, whilst others can provide the vital services. But getting innovative organisations to share their intellectual property, and service providers to share their income, is proving tricky. I’d be delighted to work specifically with the following groups to bring together groups of public service commissioners and existing and innovative providers to build a consensus and prepare for an innovative service:

Charities which commission personal care and health care services
Capacity builders and those who fund innovation
statutory commissioners eg Local Authority, Social Care, NHS

References
1. Dudman, J., Social care professionals cautious over new funding plans, in Guardian Public. 2009, www.guardianpublic.co.uk: Internet.
2. Porter, M.E. and E.O. Teisberg, Redefining health care : creating value-based competition on results. 2006, Boston, Mass.: Harvard Business School Press. xvii, 506 p.
3. Minney, H. Innovation - Case for Investment in Social Care. Performance Improvement and Outcomes Realisation 2008 [cited 2009 16/07/09]; Skills for Care workshops in North East]. Available from: http://minney.org/benefits_third_sector.
4. Minney, H. Commissioning Innovation. Performance Improvement and Outcomes Realisation 2008 [cited 2009 16/07/09]; Available from: http://minney.org/Commissioning_Innovation.

"All bets are off" as David Nicholson tells NHS to prepare for cuts (HSJ 4June - updated Pulse 27Nov09). Massive investment over the last 8 years hasn't improved productivity (HSJ 28May). PCTs aren't making use of the wealth of experience and enthusiasm available through Practice Based Commissioning (PBC) (Primary Care Today May/June 09). The same old ideas are put forward as the solutions to all our problems - more care out of hospital, more innovation, more work led by nurses, more Health centres, more salaried GPs. Why haven't these 'obvious' solutions delivered? I'm not convinced that inertia is the complete answer.

Changes which deliver better care, more effectively, can only occur at decision points on care pathways. Many health service staff are engaged in the delivery of care according to a protocol. Therefore we need to focus on the decision points, and necessarily on the decision-makers. For example, GPs decide which pathway to refer a patient onto; community nurses very often provide the care on that pathway, but don't change it. ECPs (Emergency Care Practitioners) make a diagnosis and a decision where to refer when they attend the scene of a fall, an accident, an emergency; advanced paramedics or alternately trained paramedics have limited protocols and limited options.
salaried GPs employed by PCTs are no substitute for the family doctor. A salaried GP does not become a point of trust for a doctor (70% of GP appointments result in no referral and no prescription; patients attending to be told that they can carry on as they are, or to be listened to - by an old friend or a family friend, not by a stranger); a salaried GP moves from practice to practice according to their state of life, perhaps in the big city when young, in the suburbs when the children are school age, and to the country when the children leave home
care needs to be given in the most APPROPRIATE location, and by the most appropriate staff, regardless of politics and organisation. For a great many patients and a great many conditions, hospital is the best place for treatment. For a lot of other health care, the hospital staff may be the best, even if care is to be delivered in the community or patient home. All the suspicions about hospital staff steering patients towards their hospital for maximum income appear to be unfounded
"Redefining Healthcare" by Porter & Teisberg looked at different ways of delivering healthcare across USA, and clearly concluded that the UK system of GPs as the first point of contact is not only the most cost-effective, but also delivers the highest quality health care

Healthcare is improving (although QOF rewards for process, this is resulting in for example higher proportions of those on the CHD register with low blood pressure - see HSJ 28May 2009, same article). We do need innovation, but we must not throw the baby out with the bathwater - keep what is good, find ways to encourage what will make it better. All we are saying, is give PBC a chance.

Would it be unfair to suggest a certain naivety? Since BCCI, and probably before then, the saying "if it looks too good to be true . . ." has marked a common-sense approach to money. Putting it simply, charities should steward the money in their trust, not try to profit from it. What has happened here could happen to anyone. Some charities (Cat Protection League and another 29) had gambled, looking for the most profitable place in which to deposit donors' money. The gamble didn't pay off. Many of us are suffering because of this credit crunch, and because of the view in public sector that cuts will come and they had better remove people from jobs before it does. There is less money to go around, especially from government which is about to get a big unemployment bill and additional services bill. It would be a great confidence boost to dig charities out of a hole, but it was this "no pain" culture that got us into the banking crisis, and charities should see themselves as of higher probity than that.

I ran a break-out session at the New Types of Working Skills for Care/Skills for Health conference last week. It was very instructive – for me! I took a 4 month programme that I’ve now run twice in different contexts (http://minney.org/benefits_third_sector and http://minney.org/Benefits_Framework) and again as a whole day workshop led by Ann James CBE (http://minney.org/Commissioning_Innovation). For the New Types of Working conference I tried to present this as a 1 hour break-out entitled “A way forwards – aligning services with strategic objectives in Health and Care”. Bernice McCarthy was wrong – 80% of people don’t want to discuss WHY, don’t want to know WHAT, they simply want to know HOW do we do it. Perhaps Jay Abraham was right? Anyhow, back to the workshop. Essentially three audiences:

commissioners (statutory, NHS and social services; there were no charity commissioners in the audience);
providers (NHS, Local Authority, Independent Sector, Third Sector (not for profit); and further and
higher education.

We included at least a few from each. We started discussing how to set strategic objectives (common misconceptions such as everyone understands each other and everyone shares the same language and priorities). Then we talked about engagement – again misconceptions (everyone thinks exactly the same way that I do, and my priorities are shared). There wasn’t time to run a strategic alignment workshop (which anyway takes around 3 hours to 1 day). Some people wanted more (can we have this as a full day?), and others were disappointed (he didn’t answer the question). I look forward to feedback. If you want a programme to understand your region, I’d be pleased to discuss (http://minney.org/?q=node/44) it though I would suggest more than 1 hour with the stakeholders.

Let's be realistic: this crunch won't last for ever. And when it ends, consumers will need new products. We're going to need innovation in financial services (after all, we can't reuse the failed products of last year and preceding decades). New delivery services (keeping food miles down, recognising more purchasing on the internet, even home delivery services from a trip down the high street so you can go on spending!). New transportation options (carbon footprint again). New eating and socialising options (when facebook and twitter take their rightful place not as substitutes for an evening out with mates, but as the enabler). New everything. We could leave it to a few very talented inventors to come up with new ideas - but the things that catch on have a habit of being surprising. Perhaps we should dedicate the hundreds of thousands of people who are at risk of losing their jobs, dedicate them to creating innovation. The alternative is that society has to pay for them anyway (unemployment, mental health medication, lack of confidence to contribute for decades to come) but gets nothing back. This way (ie with government paying the same amount to their employers, as long as these workers are dedicated to discovering innovation rather than business as usual) gives people their self-esteem and puts Britain in a very very strong position coming out of the recession.

Tudor Hart's Inverse Care Law[1] states "The availability of good medical care tends to vary inversely with the need for it in the population served. This ... operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced."
This was certainly the case in 1971, to the extent that a minister for health even as late as 2001 thanked the Asian doctors and GPs that work in so many of our deprived areas, where white doctors were unwilling to work. I believe that there is much better provision of health care services in deprived areas. Yes it's far from perfect, but we're a long way forwards from where we were in 1971.
However the poor aren't getting healthier.
There could be any number of reasons for this. Cheap food of dubious nutritional value. Lower expectation of health. Lower self-responsibility for exercise and activity. others?
A revised Inverse Care Law
I'd like to propose an alternative Inverse Care Law. Simply stated:
"Those who need most, ask least"
Those who have the greatest need of health care and support, are also the ones with the lowest expectation that they are entitled to it. The rich and middle-class make full use of the health services available, including GP, A&E, urgent care centres, hospital, NHS Direct; health activities that may not be vital for continuing life but that make them feel better. The 'worried well' and 'only slightly sick'. Whereas some in deprived areas assume that it is normal to take time off work due to sickness every month, to have irritable bowel, to be tired the whole time, to get old. They don't ask for help, because they don't believe help is available
References
[1]http://en.wikipedia.org/wiki/Inverse_care_law

They say another key difference between clinicians and managers is that managers are only interested in what will make money, whereas clinicians are only interested in delivering the highest quality. I don't know if you've studied Lean methodology in any detail? It's a series of techniques for improving the delivery of services and products, and NHS Institute for Innovation and Improvement has released a number of guides of its Productive series, Productive Ward, etc. This is about getting people to question the way we do things round here, to see if there's a better way.
Community Engagement
It's about getting staff engaged locally, down to their own individual teams, and some of the techniques including management by walking around and process mapping involve everyone working together - sponsors (typically executive directors), senior doctors, consultants, nurses and AHPs, hospital staff or primary care health care staff (staff nurses, staff medical, etc) - to map out how the patient journey is done now and where are the things we do that don't add any value. For example, the patient waiting in the waiting room doesn't add any value. The patient going home and coming back for another appointment doesn't add any value. Writing labels on blood samples going for diagnosis adds value, but is there a better way (adds more value or takes less effort). Recording the number of patients waiting only adds value if you do something with the results.
Staff Evaluation
Staff themselves are involved. We work together. We learn from each other, understand why a particular action or a particular step is necessary, and jointly evaluate and agree what isn't necessary. The service is better quality, because there's less waste. The service is lower cost/ uses less resource, because there is less waste.

Focus on the individual patient and their immediate need can conflict with community welfare, conserving economic resources, supporting the criminal justice system or simply making money for the physician or his employer. Is a doctor is almost obliged by his/her vows as a doctor to ignore Public Health priorities or the strategic objectives of the health economy to serve the immediate needs of the patient in front of them?

What does this mean in practice?

Διαιτήμασί τε χρήσομαι ἐπ' ὠφελείῃ καμνόντων κατὰ δύναμιν καὶ κρίσιν ἐμὴν, ἐπὶ δηλήσει δὲ καὶ ἀδικίῃ εἴρξειν. I will prescribe regimens for the good of my patients according to my ability and my judgement and never do harm to anyone. Further, in GMC's "Good Medical Practice (2006) - Good Doctors" Patients need good doctors. Good doctors make the care of their patients their first concern: This focus on the individual patient and their immediate need can conflict with community welfare, conserving economic resources, supporting the criminal justice system or simply making money for the physician or his employer. This means that a doctor is almost obliged by his/her vows as a doctor to ignore Public Health priorities or the strategic objectives of the health economy to serve the immediate needs of the patient in front of them.

What does this mean in practice?

Management of resources, and treating immediate need, are difficult bedfellows. The bridge between them is Public Health, or a proactive attempt to prevent ill-health through resolving the environment that will ultimately (and probably already causes) cause poor health. Actions to reduce smoking can be perceived both by physician (improved health) and the economist (reduced future cost, reduced lost production) as beneficial to society. Finance managers can see the long-term benefits, but sadly this year's budget has to provide both for this year's clinical needs (last year's smokers), and extra resources for the proactive programme that will reduce next year's bill. It's a difficult decision and it emphasises the importance for doctors to recognise the legitimacy of public health targets and the need for planning, and of course for managers to understand the constraints under which doctors work.

By now, just about everyone has a Myers-Briggs profile, and probably a whole lot of other profiles too. We've learnt that not only are other people different but that other people's styles can complement our own - round out the square bits in our own personality giving the team a smoother ride.
But how does this affect how we communicate with people (and I'm thinking particularly about the difficult interface between front-line care professionals and managers/ strategists/ budget holders)?
Sould you like a sure-fire way of both understanding, and being understood, by "the other side"? I'm not promising you'll always get your way, but with understanding on both sides, a third way can be agreed with the best of each and something better.
So what's the secret?
Well, the "how" of engaging with care professionals will follow a more comprehensive exploration of what engagement is really about. In simple terms, 'know your enemy' - there's no point in me explaining in detail how to cut with a saw when your requirement is to staple bits of paper together.

That doesn't look like the headline for a professional article!
When I seek joy and only joy, all else comes to me. I know right now that I have a lot to learn, that I've spent far too long worrying about being professional, protecting my reputation, earning money, pretending I'm seeking freedom when in reality I'm frightened to set out on my own.
It has taken a real effort of will, and a real effort of surrender, to get to this point.
So I'm not trying to do what I ought to do.
I enjoy delivering benefits workshops, and helping people to understand what can be achieved, what you and I can each achieve, and to bring together the teams and the inspiration to achieve it. I enjoy the workshops, the knowledge transfer, the stretching that your questions bring about, and the nuances and fine tuning of ideas that result from every benefits workshop. I'm thrilled by the mental and intellectual demands that competence-based workforce planning, especially cross-organisation and whole community workforce planning such as School Health workforce or bigger than this, children's workforce, demands. And I lap up the adrenaline rush of gathering enough information to make an accurate but rapid assessment of where a number of initiatives and projects are, enabling the leaders of those projects to make good decisions about their future.
Live with passion!
Turn your working days into passion as well as your nights - life's too short to earn to pay the bills

It's always fascinating to go to a national conference (as long as you don't do this often)
Speaker after speaker explained their vision for PBC (practice-based commissioning - the policy of inviting groups of GP practices to review needs for their patients and make recommendations to their Primary Care Trust for changes), all the way from "the decision-making for care should be in the hands of the GPs" (Department of Health) to "we formed a consortium representing 97% of the population of the PCT, and now we're proposing services we might run".
Same old same old. The key issues remain:

real figures relating to demographics (how many, what conditions would be expected) and activity (how many treatments currently provided)
understanding the local process for acceptance of business cases for new services, and having followed the process, having the business cases accepted
vertical and horizontal integration between different organisations with different priorities (we're all on the same side - how do we have different priorities?)
trying to build incentives which bind unlikely bedfellows, and hoping that the incentives will actually lead to better care for the population and service users
potential for conflict of interest when a GP refers to a service which they themselves provide
long-term solutions in an environment where "long-term" can only ever mean up to the next policy change - if you haven't got a return on investment within 3 years, the ground rules will have changed before you do get one

there are clearly some excellent and outstanding initiatives going on, sometimes with NHS blessing, and sometimes in spite of NHS. Real risk remains with the initiators, and as more not-for-profit organisations are created to deliver new services, this becomes one-sided leaving the initiators with all the risk and no opportunity for reward.

A frequent comment from the audience was "how can you do it that way when we aren't allowed to?". It is painfully clear that different PCTs have set different environments for PBC, and what works in one part of the country only works because of co-operation. A quick look at the World Class Commissioning (WCC) scores suggest that the PCTs with the highest scores also have the most interesting PBC initiatives.

I'm certainly going to follow up many of the presenters who have useful and valuable solutions and/or contributions. I'm going to follow up with NAPC on how to make the politics work. And I've come away with many new ideas and new things to try. Thank-you

There seems to be an enormous gulf, in healthcare, between those that care for patients, and those that administer. Neither side seems to trust the other – clinicians accuse managers of thinking only of costs, and in return managers complain of a refusal to recognise limited resources. This applies in other environments, eg social care, where care professionals and management also seem to struggle to bridge the communication gulf.
I was at a NAPC dinner the other evening, and met a person who was amazed I believed that it was possible to forecast. I asked the question “what is the likelihood that someone will win the lottery this week?” Of course the answer is “anybody – pretty much certain. A specific ticket – 14million to one.”
Having spent time helping teams to work together in contentious areas such as service redesign, I present my conclusions on the differences (I’m going to use the term ‘administrator’ throughout, as I believe the problem set in when administrators took on the title Manager and thought they were important):
They think differently
Administrators and clinicians have different views on the world. This reflects the kinds of people that gravitate towards each role.
Doctors, nurses and AHPs like working face to face. They have endless patience to address each individual need, but it makes it difficult to then take a helicopter view and say “how many next year?”, “what skills will be needed?”, and “what do I prioritise and what do I do with the ones who aren’t prioritised?”. Administrators provide the complementary function.
Care vs statistics
This focussed ‘one by one’ approach can lead to different responses when each looks out into a full waiting room. A natural reaction from the clinician is “I’m so busy, how will I manage?”, whereas the administrator should take the view “I need to plan to manage” – but then that is what the manager has prioritised their time for, planning ahead.
Similarly the clinician looks at the patient presenting and says “what condition do they have?”. Statistics play a relatively minor role in this process. The administrator looks at the demographics and disease prevalence, and says “what resources do I need in place to meet the likely requirements, and to provide a response in the event of something serious but rare?”. The Administrator has the phenomenally difficult task of deciding how to prioritise limited resources, and who to say “no” to. Mind you, the clinician has to look the person in the face!
Planning ahead
There is, there will always be, more need than there are resources. Demographics change over multi-year periods, eg the number of people living with long-term conditions, the numbers alive in different age decades and their changing needs. Two studies illustrate that quality care is not dependent on the amount of money spent – one done by me on World Health Organisation data shows that within a limited range more money spent = longer life, but USA spends much more than anyone else (both as % of GPD, and also because GDP is so high per head) without getting better results:

after
Porter & Teisberg who quoted Friedman, Milton in "How to Cure Healthcare" pg 20
And the one below quoted in Porter & Teisberg pg 29 showing that the UK model of GPs to see all patients and refer those who need further treatment to a specialist not only gives higher quality care than the patient self-referring from one specialist to the next, but is also cheaper:

(incidentally, why are we in UK trying to imitate USA when they are trying to imitate us?)
The administrator’s task
To set the strategy, or if it is already set, to plan how to comply with the strategy in a specific situation. This means taking advice, gaining understanding of the clinical requirement, understanding the resource requirement, whether different skills or a multi-disciplinary team is required, and how.
It applies today, and it applies in short, medium and long terms.
Bridging the divide
We’re going to present specific techniques for getting working groups that work together, and illustrate with some successes (both mine and ones I’ve studied). The first step is to acknowledge the difference.