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NEWS. SUCCESS AND ADVICE

NEWS, SUCCESS AND ADVICE

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Welcome to my blog

 

Scott Mckenzie

 

NHS Management Consultant / Working at Scale

 

"My biggest enjoyment comes from knowing the work we deliver supports our clients to improve the quality of the services offered to patients, and as a direct consequence also improves the outcomes achieved for the patients. My goal is to deliver transformational change in the NHS, working across primary, secondary and community services, in support of the Care Close to Home (CCH) agenda"

 

Scott has worked in the healthcare profession for over 20 years. With an extensive commercial background in business, project and account management, Scott's expertise and track record in healthcare was established following a number of years specialising in the pharmaceuticals sector. Scott is now widely recognised as a specialist provider of support to the NHS on all aspects of service transformation, commissioning and service provision.

By Scott McKenzie, Nov 23 2017 08:59AM

"I have had to watch the decline of academic forensic psychiatry in this country"

Professor John Gunn

John Gunn CBE
John Gunn CBE

My name is John Gunn I am a retired forensic psychiatrist and I've been asked to write a blog about what I do and why I like it. The word forensic simply means legal; therefore a forensic psychiatrist is someone who specialises in the management of patients with legal problems, usually offenders. It has nothing to do with pathology or dead bodies.


Being a psychiatrist is an immensely satisfying job; it is concerned day in day out with people in various forms of mental distress. There are a variety of mental disorders such as schizophrenia, bipolar disorder, mania, depression, anxiety, panic attacks, phobias, drug taking, behaviour disorders and so on. Many of these conditions are life-threatening but many of the conditions are also eminently treatable.


Forensic psychiatry focuses on disordered people who find themselves in conflict with the law. Some are very impulsive, others are violent, some are driven by insatiable deviant and illegal sexual needs, for example, some have a desire to have sexual activity with children. Much antisocial behaviour arises from a disturbed childhood, frequently an abused childhood. Disorders of this type can be seen as existing in a vicious circle; abuse leading to damage and damage leading to abuse. The role of the forensic psychiatrist is therefore to identify disorders that will lead to legal conflict and prevent them wherever possible, and if necessary provide treatment after the event in the case of, say, a violent outburst or illegal sexual activity.


Psychiatric beds in hospitals have been severely reduced in numbers in my lifetime. It has been thought to be cruel and unreasonable to detain people just because of their mentally disordered thinking. It has also been thought that short periods in hospital followed by long-term treatment in the community is the best way to manage almost all psychiatric conditions. However, most people want antisocial behaviour contained in some way and hospitals with facilities for treating people with antisocial mental disorders have actually increased in number during my lifetime, but investment has not kept up with demand and there is always a shortage of beds, doctors and nurses in all branches of psychiatry.



The satisfactions of treating someone who is in great distress or who has had their life seriously damaged by their thinking and their behaviour is, are enormous. It is doubly satisfying if it is apparent that the patient can have both their symptoms relieved and also their behaviour changed so that they become safe to other people. An outpatient clinic of previous offenders, who are now keeping within the framework of the law, even though they may have residual symptoms and even though they may find work and accommodation extremely difficult, has been a very rewarding experience for me for many years.


Working with offenders means that the forensic psychiatrist collaborates with, not just the usual health professionals that all psychiatrists work with, such as nurses, social workers, psychologists and occupational therapists but also lawyers in advising them how to deal with cases that come before the courts, and police officers who manage threatening and dangerous behaviour. For example, I and my colleagues were retained for some years by to the Metropolitan police to give advice about the management of siege situations in which a very distressed individual is threatening to kill other people, often members of his own family. Domestic violence comes within the purview of forensic psychiatry but is rarely seen as a top priority health issue even although many of the murders and the suicides in Britain are related to domestic conflicts and are extremely costly both in emotional and in financial terms.


Not all forensic psychiatrists are academics, but I always had an interest in research and teaching and took up academic posts at the Institute of Psychiatry for most of my career. My first substantial research was to conduct a survey of people in prison who also had epilepsy. At the time I did this in the 1960s it was widely believed that people with epilepsy were more likely to be violent than other citizens. My survey did indeed show a larger number of individuals in prison with epilepsy than one would expect by chance. However, it became clear that this was not due to people with epilepsy being especially violent or indeed especially criminal; it was the other way round, people who were at the bottom of the social spectrum, and in addition had the horrible disease of epilepsy, were more likely to be institutionalised in one way or another than other people.


This study led me to a lifelong interest in prisons, which tend to be our forgotten institutions. Originally they were built as holding places for people who were to be executed or transported. As liberal ideas gained traction in the community the prisons became places of punishment in themselves and right up until the Second World War they were institutions where cruel punishments were handed out fairly freely; punishments such as solitary confinement, lashings, bread and water diets and, in the case of murderers, execution. This all began to change as I was taking my first interest in prisons and slowly, until very recently, they developed a strong rehabilitative and therapeutic role for people with antisocial behaviour. Recently this progress towards rehabilitation has been several damaged by cuts in resources.


It's not true to say that people have ever been sent to prison for treatment. Anyone who could show the main problem was a psychiatric one should have been, and on occasions was diverted to a secure psychiatric hospital. However, many mentally and some physically disordered people were not able to receive NHS treatment due to a lack of appropriate investment. One really big problem for people who get themselves into prison is what one might broadly term self-medication - the taking of illegal drugs, and probably even more commonly the taking of our favourite legal drug, alcohol. All these substances damage the brain and produce abnormal and antisocial behaviour. Part of the function of any therapeutic approach is to try and wean individuals away from these substances, although it is very difficult because even within the prison walls most brain damaging substances are freely available.


Prisons, during my lifetime even developed psychiatric treatment in the form of either individual psychotherapy or in a therapeutic community. These our rare resources are nowhere near sufficient to deal with the numbers of people who need them. More recently psychology services have been introduced into prisons and they attempt to treat people with impulsive behaviours but particularly with deviant and aggressive sexual drives. The other group of people forensic psychiatrists work alongside our probation officers. Some offenders can be sentenced to probation rather than imprisonment and during their period of probation they will be attended to by a probation officer who sees them regularly and tries to advise them about ways of keeping out of trouble.


As I mentioned above austerity has damaged the rehabilitation work which prisons in England were undertaking. When Christopher Grayling was appointed as Minister of Justice he decided to drastically reduce the numbers of trained and skilled prison officers. This has had the predictable effect of increasing prison violence both to other prisoners and to staff, increasing the suicide rate of prisoners, damaging or stopping treatment programmes, and generally making prisoners more likely to commit offences. It also produced an upsurge of illicit drug taking which made the prisons even more unmanageable and led to riots. Not only did he do all this but Mr Grayling also privatised half of the English probation service so that staff and prisoners on prisons and probation and parole were handed over to inexperienced profit making private companies. As Richard Ford in the times on Wednesday, 2 August 2017 told us the number of offenders charged with murder or other serious violent crimes whilst under probation supervision has risen by 25% since the partial privatisation of the service. The Ministry of Justice has also had to pay a bailout of £21 million to some of the privatised community rehabilitation companies. All this in the name of "economy" and "deficit reduction". Special education classes for politicians might produce a better result.


Since I have retired I have had to watch the decline of academic forensic psychiatry in this country. Neither the universities nor medical charities have taken an interest in the serious reduction of research and teaching related to this specialty. Professorial chairs set up at the end of the last century and now lying vacant. In an attempt to highlight this problem and to raise some funds for academic forensic psychiatry, especially research in this vital area, my wife and I have set up a new charity Crime in Mind which aims to raise funds and public interest in this work. To recover even the position which pertained in the 1990s is a daunting and uphill task but we believe it is essential if money is to be saved, crime is to be reduced, and humanitarian medical developments are to continue for a very unpopular group of our citizens who suffer from very complex needs.


If you would like to donate to Crime in Mind you can do that here: http://www.crimeinmind.org/donations/4588369818




By Scott McKenzie, Nov 15 2017 11:45AM

Together we can do so much
Together we can do so much

“Alone we can do so little; together we can do so much”

Helen Keller


Last weekend I was talking to a Consultant Gastroenterologist friend, who, by his own admission, was not firing on all cylinders. He’d had some long and challenging shifts in the hospital in which he works, followed by a dash to present at a conference, followed immediately by a return to the coal face of patient care.


Much of my work involves supporting primary care, and we reflected on the challenges across the entire health and social care system, on the responses of healthcare professionals to those challenges, and on our own experiences in the parts of the system in which we work.


My friend reflected on the hours that he puts in, way above and beyond his contracted hours for no extra recompense, to make sure patients receive the care they need. We talked about the workload and responsibilities of GP Partners, as business owners and clinicians, who put in whatever hours they have to in order to manage both sets of responsibilities, and the salaried GPs and locums who, in general, are now earning pretty much the same as GP Partners (especially when oncosts are taken into consideration), but limit their responsibilities and workload, in the main in order to avoid the burn out suffered by many of their Partner colleagues, and have some kind of work/life balance.


This was something that my friend hadn’t considered before; he hadn’t appreciated that primary care is currently relying heavily on an ever-shrinking number of GPs who will work 12-hour plus days, many of whom are heading rapidly towards retirement. What happens then?


He talked about the quality of referrals he receives, concerned that in his view more than half could have been managed in primary care, wasting both the patient’s time and his. Equally we talked about the volume of work being passed inappropriately from secondary care back to primary care.


What a sad and sorry state of affairs.

Once upon a time, not that long ago, primary and secondary colleagues knew each other well, and were able to pick the phone up to discuss their patients, ask for advice, talk about transfers of care. The point being that they saw it being about their patients. Joint and shared responsibility. Joint and shared care. Inappropriate referrals, the feeling of work being dumped; it just wasn’t like it is now, where care professionals often feel pitted against each other, all trying to protect their bit of the system from being overwhelmed: hand off care to the next part of the system in order to survive.


There are a myriad of reasons for this apparent breakdown in professional relationships, not least brought about by unhelpful systems and technology like choose and book (or e-referrals), but unless we fix it, and re-build those relationships and professional respect, how on earth can we even begin to think that Accountable Care Systems, let alone Accountable Care Organisations, can start to meaningfully take shape? With some exceptions that prove the rule, we’ve never been further away than we are now. Self-preservation and survival of the onslaught of patient demand against the backdrop of falling and failing resources, is the name of the game.


But there are examples of where the tide is turning, many of them in the guise of Primary Care Home

http://napc.co.uk/primary-care-home/


And one of the keys to turning the tide? Engagement. Engagement of all stakeholders in the process: commissioners, providers, patients, third sector, all working together to build the professional working relationships that underpin patient-centred, population-based care, creating a community for change. Taking us back to, and better than, “the good old days” before systems like choose and book drove a professional wedge. We want to, and need to, get back to feeling that we’re all in it together for the benefit of our patients and the communities we serve. To have care professionals not feeling that they have to be in a position where they place strict limits and parameters on the work they will and won’t do: a health and social care system cannot survive on that kind of premise. What good will there is, is wearing thin.



So take a leaf out of Primary Care Home’s book, and properly and meaningfully engage, from the ground backwards, and form the firm foundations for Accountable Care. Quite apart from anything else, to do otherwise risks the longevity and commitment of the health care professionals that we will all rely upon at some point in our lives, if we don’t already. And then what do we do?


I’d really rather not find out.


Sarah Cousins

Sarah Cousins Consultancy Ltd








By Scott McKenzie, Oct 31 2017 11:51AM

“Without faith, nothing is possible. With it, nothing is impossible.”

Mary Bethune , Educator



Keep the Faith! One of my favourite tracks by Bon Jovi. I have heard it literally hundreds of times; primarily when my son, Neil, has had a bad day at the football. He will happily listen to that same track over and over again, reminding himself more than anything not to lose faith – all part of his Aspergers Syndrome.


This week I found it by accident on iPhone shuffle while in the gym, but it reminded me of the ups and downs in my life, and that you really do need to “keep the faith”.


I found myself in reflective mode, looking back, not for any other reason than to remind myself of what I’ve been through since I became self-employed in 2005. Nothing you are told, and nobody you speak with about it, really prepares you for the reality.


There have been many highs, all celebrated in equal measure: no matter how big or small the win, they are all celebrated. These good times are unfortunately countered by the lows and failures, most of which of course are unexpected or at least not planned for. However, I have learned that when running your own business you must expect setbacks and failures. The key is that you learn from each and every setback and don’t repeat it. At these points you must “keep the faith”; that you will evolve, you will find a way and you will come through it.


That’s a model followed by anyone who has gone on to achieve outstanding success. Whether in the field of business, sport or life in general, the ultimate success is often built upon a tower of failure, BUT with lessons learned to avoid a repeat.





I have read hundreds of books and biographies and all contain the highs and lows. Indeed, they paint a picture that you should expect failure and that you need to be ready for when it happens. The same books/people also highlight that it’s the failure to adapt to new market conditions that causes many of the successful businesses/people to fail. Had they spotted the problem, agreed changes and acted, continued success would have followed. By ignoring the problem it will not get better, and sometimes the damage done is fatal.


Nobody I have come across has gone from start to outstanding success without failures and setbacks. I would also add that there are very few, if any, that are still doing today exactly what they did when they started out doing whatever it is they do. All successful businesses evolve and continuously develop their offer. For example, look at cars today, where we now have a whole range of fully electric vehicles, unheard of only a few years ago. To that we can add even recent developments such as mobile phones and MP3 players, which continue to evolve – I’m now using iPhone 8! The lists are long and there are many examples of continual development and improvement in business.


No company is immune to change and resistance is likely to lead to failure of the business.


The same applies to sports where teams reach a peak of performance and try to maintain that for as long as possible. They add new players and rotate squads to maintain their peak. Interestingly, since the English Premier League (football) was formed there has been one team, Manchester United, who have won it three years running, but nobody has matched that or been able to make it four years running. This demonstrates you cannot stand still or you risk failure.


Many General Practices now find themselves in a situation they have not planned for, with shrinking income, increasing workload and an inability to recruit or retain the right teams. If that’s you the first step is to admit you have a problem.


From there you can start to look at and review your plans and aspirations: what’s working, what’s not working, where can you see problems, and where can you see the need for change has been ignored? The hardest part is to admit you may have problems that need to be addressed. If you accept that, the next step is to stop ignoring the problems and to start developing a plan for action that takes you from where you are now to where you want to be. You may also want to seek out some help and support.


Nothing should be done to you or come top down. This is your business, meaning it is your decision to make. This is likely to mean making some very tough decisions to keep your business viable (resilient and sustainable). With your plan, you can be confident in your decision making. Some you will get right and some wrong; the key is you keep moving forwards.


If you are going to seek help, look for people who can demonstrate outcomes and a long track record of delivery. I would always challenge anyone not prepared to take their own advice, or where they have no track record of delivery or achievement. If you stop and think for a moment, most busineses hire on the basis of accomplishment, achievement and delivery. They appoint people to roles that build upon stellar performance and credentials in the expectation of that delivery continuing and improving. They look for continued growth of the individual in the new role, based upon their performance to date.


Consequently this must apply to your business, and indeed to the development of GP Federations, Super Practices, hubs of 30,000 to 50,000, MCP, PACS or ACS. When appointing anyone in to support you I encourage you to explore the credentials of delivery and outcomes. Are the people you appoint able to deliver what’s required? Can they demonstrate the accomplishment of achievement, outcomes and progress? Can they provide references for their work; people you can pick up the phone to and speak with? If not, I would stop and think again.





If you take positive action in the right direction you can and will turn things around.


Lastly, in the words of Bon Jovi; “Faith: you know you're gonna live through the rain - Lord you got to keep the faith” Written by Richard Sambora, Desmond Child, Jon Bon Jovi.











By Scott McKenzie, Oct 25 2017 04:34PM

'If you think of yourselves as helpless and ineffectual, it is certain that you will create a despotic government to be your master. The wise despot, therefore, maintains among his subjects a popular sense that they are helpless and ineffectual'

Frank Herbert, author of Dune

Having written last week about the need to engage General Practice in the development of New Models of Care, and not to try and impose anything top down in order to avoid the probably outcome of complete failure, this week I came across a worrying example of precisely that.

I found a report that highlighted an “STP covering a population of 1.4 million, (where) there are 11 organisations – two CCGs, three local authorities, four acute providers, a community services provider and an NHS mental health trust, working together to develop four ACPs (Accountable Care Systems and Partnerships)”.


There is no mention of General Practice having been engaged at all; nothing, nil, zero, zilch. I suspect the CCGs will have been counted as representing General Practice; however, the difficulty with this is that CCGs can only represent themselves as commissioners, and not - absolutely not - as providers (you can’t have it both ways, CCGs, and cite conflict of interest when it suits you, and then mention nothing when it doesn’t).

On the other hand, it could easily be that General Practice has been missed completely; it wouldn’t be the first time that’s happened.


Every New Model of Care requires General Practice at the heart of it, operated at scale. So, on that basis, why would they not have been formally engaged as providers in developing this?


If you are leading the development of your local Accountable Care System (ACS) https://www.england.nhs.uk/2017/06/nhs-moves-to-end-fractured-care-system/ (and, in time, Accountable Care Organisation (ACO)), Multispecialty Community Provider (MCP), which also includes the Primary Care Home model (http://www.napc.co.uk/primary-care-home), or Primary and Acute Care System (PACS), what have you done to fully engage every General Practice, before you start to bring in the other stakeholders?


I ask again: did you stop and, for example, ask what red lines they have, what they enjoy about the way they work now, what things they might be flexible around, what could be started quickly, the needs of their local population, the workforce and wokload they have and would like in future, and did you ask what’s on their wish list? Did you offer up a guarantee that you would include their input and feedback to develop the vision, or instead did you come at the process from top down, with the need for them to “engage” to create the “new system”, with a vision already created by a small sub-committee of people who will tell everyone where they are going wrong, and how implementing “x” will create exactly what “we” need?


Disengagement of General Practice, whether it be a conscious decision or otherwise, will lead to failure, as every model is predicated on General Practice at its heart.



So why would you not openly and formally engage them? What are you worried about? What have you got to lose that trumps what you stand to gain?


To be engaged requires the winning of hearts and minds; in respect of the purpose of the engagement, followed by the agreement of a joint vision that will be pursued within an agreed timescale. Anything less is at best nothing more than a meeting and at worst a waste of time, as it will not reach a conclusion and so nothing will change due to that lack of engagement.


The engagement process I use is tried and tested. I have been using it since 2005 when I formed the company. From developing PBC Consortia, to GP federations, super practices, Primary Care Home, New Models of Care or any sort of pathway redesign, we have used the principles of the engagement and inclusivity of all stakeholders involved in the process. Whilst challenging, it ensures that the vision created is one that has been developed by all those who have a role to play, whatever that role, leading to buy-in and ownership of what you create, as a community for care and bringing about a critical mass for change. This model deliveres outcomes because people own the problem and the solution.


This is not a complex process, but it delivers remarkable outcomes from three workshops:


• Workshop 1 – Winning Hearts and Minds

• Workshop 2 – Developing the Vision

• Workshop 3 – Implementation


Between the main workshops, we hold mini workshops, to ensure that those not able to participate in the main workshops have an opportunity for input; these would usually be a two-hour session, and the outputs of the mini workshops are fed into the start of the next workshop.


Ultimately, by taking this approach and developing vision and change in the way we describe, you will get the outcomes you want, need and have agreed.


Once again, I encourage you to avoid top down reorganisation and instead engage every stakeholder right from the start. If you give them a voice and engage them in leading the change, your change project will deliver. It’s not easy, but it gets real and sustainable change happening in a positive and constructive way, and also ensures resilience for future challenges. However, the NHS – and care more broadly – is in freefall, and the time is now for those in positions of responsibility and accountability to step up the the plate and accept that taking an easy route just won’t cut it. Drive engagement; drive ownership, and create sustainability – come on STP Leads and CCGs: are you up to the challenge?




By Scott McKenzie, Oct 18 2017 09:28AM

“When people are financially invested, they want a return. When people are emotionally invested, they want to contribute.”

Simon Sinek

Engagement: “an arrangement to do something or go somewhere at a fixed time”


Meeting: “an assembly of people for a particular purpose, especially for formal discussion”


So, according to these definitions, a meeting is not the same as engagement.


In order to be engaged it first requires the winning of hearts and minds in respect of the purpose of the engagement, followed by the agreement of a joint vision that will be pursued within an agreed timescale.


To better explain: if we take a proposal of marriage as an example it has all the criteria I have just described above. Hearts and minds have been won; there is a clear vision of what the future will look like and, in most cases, we quickly have a wedding timescale that the couple are working to. Lo and behold, as a result, we get an outcome: normally, albeit not always, a wedding. A perfect example of true engagement.


So why do we find it so difficult to translate that process into our working lives, and instead have any number of meetings, as well as formal and informal discussions, that invariably go nowhere?


This is probably my biggest concern around the development of New Models of Care: are we genuinely engaging General Practice as an equal partner in their development? Disengagement of primary care, whether it be a conscious or unconscious decision, will lead to failure, as every model is predicated on General Practice.



If you are leading the development of your local Multispecialty Community Providers (MCP), which also includes the Primary Care Home (http://www.napc.co.uk/primary-care-home), Primary and Acute Care Systems (PACS), Accountable Care Systems (ACS) https://www.england.nhs.uk/2017/06/nhs-moves-to-end-fractured-care-system/ and, in time, Accountable Care Organisations (ACO), what have you done to fully engage every Genetal Practice, before you start to bring in the other stakeholders?


Did you stop and, for example, ask what red lines they have, what they enjoy about the way they work now, what things they might be flexible around, what could be started quickly, the needs of their local population, the workforce and wokload they have and would like in future, and did you ask what’s on their wish list? Did you offer up a guarantee that you would include their input and feedback to develop the vision, or did you come at the process from top down, with the need for them to “engage” to create the “new system”, with a vision already created by a small sub-committee of people who will tell everyone where they are going wrong, and how implementing “x” will create exactly what “we” need?


I am already seeing huge areas being swallowed up in visions created by small teams who then want to “engage” everyone with that vision. This misses the point by a long way and will end in failure. In this model you have already built and assumed resistence by not including everyone from the start.


To be clear, the current top down model is based on a once successful management approach, where a parallel organisation exists – the steering group or sub-committee approach - with the chosen few making decisions for the many, and then only engaging with stakeholders once the direction or initial plans have been created. While this process once worked, in today’s environment it is no longer fit for purpose.


If people aren’t involved from the beginning, they are more likely to resist and obstruct change, even when the ideas are good. People recognise that they are being sold something rather than being asked for their input from the start.


Health and Social Care is in the midst of one of its most difficult periods since it came into being. Change is not just necessary, it is now an urgent imperative. But are your teams equipped to deliver the required change effectively and efficiently?


By working with us, we will support you through a new change process that will give you the results and the sustainability that you need, whilst teaching you the skills to move forward in the future.

Securing your organisation for the future, our programme is founded on principles of the engagement and inclusivity of all stakeholders involved in the process. Whilst challenging, it ensures that the vision created is one that has been developed by all those who have a role to play, whatever that role, leading to buy-in and ownership of what you create, as a community for care and bringing about a critical mass for change.


Following an initial meeting with those who are leading the process, we will facilitate three one-day workshops, to be held ideally 4 to 6 weeks apart. The workshops will involve as many of the stakeholders as possible and we work with you to ensure that all members have an input. Between the main workshops we hold mini-workshops, to ensure those not able to attend the main workshops have the opportunity for input and ownership.


• Workshop 1 – Winning Hearts and Minds

• Workshop 2 – Developing the Vision

• Workshop 3 – Implementation


Between the main workshops, we hold mini workshops, to ensure that those not able to participate in the main workshops have an opportunity for input; these would usually be a two-hour session, and the outputs of the mini workshops are fed into the start of the next workshop. These ensure the ownership of the vision and support the need for critical mass in acceptance and implementation of the plans by involving as many of the stakeholders as possible.


At the end of the programme, you will have built a community for change, of fully engaged members, who will genuinely own an implementation plan for your New Model of Care. They will have mapped timescales and will already be making the agreed changes and taking the steps to deliver the vision they created.


You will have achieved this through proper and meaningful engagement: “an arrangement to do something or go somewhere at a fixed time”.


Ultimately, by taking this approach and developing vision and change in the way we describe, you will get the outcomes you want, need and have agreed, and not just another talking shop that achieves and delivers nothing. Given the pressure that the entire health and social care system is under, if the time to re-think the way in which change is developed and delivered is not now, then when?








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