1. Transforming systems Connected Health Campus Keynote Dr Martin Connor Deputy CEO Trafford PCT May 7 2009

2. Sound familiar? “ [There was]…a panoply of ‘special commissioners’, backed by their own bureaucratic apparatus, for different facets of the four year plan, often without clear lines of control, not infrequently overlapping or interfering… It was a recipe for administrative and economic anarchy” Ian Kershaw, ‘Hitler’ p. 367

3. The strategy needs not to be about marginal adjustment but about system transformation

5. CASE STUDY ONE: A collapsed healthcare system

8. Individual specialties – maximum treatment waiting times Case Study One: Northern Ireland Access Specialty Sept 2002 Cardiac surgery 5 years Ophthalmology 5 years Orthopaedics 7 years

9. Surgery waiting 2002 - 2007

10. Outpatient waiting 2002 - 2007

11. CASE STUDY TWO: A failing inner city comprehensive school

12. ‘ Sink school’ cycle of low attainment In this cycle, results will always be poor Results Spare capacity Directed entrants Traditional recruitment Behaviour standards We start here with a history of poor results and behaviour problems. This impacts on our recruitment from our feeder schools, giving small Year 7 groups… … which results in a lot of spare capacity. This means very high numbers of non-traditional entrants destabilise the school In the absence of an effective behaviour management strategy, this causes a major deterioration in standards Which leads to poor results

13. Aaagh, that’s my kids in there…

14. This was the financial timebomb…

15. KEY CONCEPTS

16. KEY CONCEPT ONE: DROP THE PILOT It’s not about pilots because: They suffer from the problem of scope ‘ Transferable solutions’ don’t transfer Solutions at scale are different in kind to successful projects – Because of risk (and therefore permissions) Because of management resources Because something will happen that will touch everyone – this is scary

17. KEY CONCEPT TWO: WHOLE SYSTEM CHANGE MEANS A WHOLE DIFFERENT APPROACH If it’s not about pilots, then what is it about? It’s about the top of the shop ( first … to make the strategic offer authentic) It’s about the patients (nothing about me without me – populations too?) It’s about the data and information (frequency, quality, timelag) It’s about the doctors (for permission and insight… and when the going gets tough) It’s about the nurses and AHPs (the vanguard of the revolution) It’s about the general management (for project management, resources and assurance) It’s about the institutions (existing… and new?) And… It’s about the vision thing…

18. The difference between a vision and an aspiration: Whilst they are both about notions of a better future… An aspiration is a vague description without sufficient clarity to enable a connection between the desired future state and the next immediate action A vision is a vague description (and necessarily ambiguous to enable ownership) that is sufficiently clear to ‘reach back’ into the present and act as a guide to the range of next steps that could be taken to move towards the goal

19. KEY CONCEPT THREE: IT’S AN UNCERTAIN WORLD There are (I argue) five distinct species of uncertainty: Ambiguity (the source of most conflict, and the death of effective strategy) Vagueness (the reason for most failure from design to execution) Indeterminacy (the risk of freedom) Agent (what might the other fellow do?) Future (time goes by at one unique second per second)

20. A NOVEL IDEA

21. THE PHILOSOPHY OF LEADERSHIP Story telling Virtues Quantification Three pillars Personal Community Cosmic Gentleness Humility Compassion (Unambiguous)Definitions Diagnosis Monitoring

22. So what’s exciting NOW! (I feel hungrily ignorant – bring it on!)

23. THE TRAFFORD GAMBIT (Could we leapfrog Kaiser in the NHS through structural reform?)

24. … and secure appropriate differentiation of specialist surgery to introduce world-class models of care… … whilst bringing together the various strands of acute medicine, A&E, urgent care, out of hours and intermediate care to deliver a more effective unscheduled care system. Beds & Theatres Outpatients Primary care Community Nested Capacity We should explore the introduction of office medicine to replace the primary care/ outpatients distinction…

25. Inaugural Trafford Clinical Congress Process and proceedings 23 rd / 24 th September 2008 “ Exploring integrated services”

26. How do we go forward? There was unanimous support for the principle of integrated service provision from the clinicians that attended the Congress. During the final session, the general management community was mandated to bring forward proposals for how this might be organised. This paper lays out these proposals at their preliminary stage of development. 13

29. RESTRUCTURING A HEALTHCARE ECONOMY

30. Present high-level commissioning Acute provision PCT … and we have persistent issues of poor integration, resilience and perhaps quality… is there a structural problem? GP1 GP4 GP2 GP3 GP n Community services Non-PbR services Outpatients and diagnostics Inpatient, daycase, specialist (Independent)

31. Future high-level commissioning? Acute provision PCT And social services..? Integrated Care Record Community services Non-PbR services Outpatients and diagnostics Inpatient, daycase, specialist GP1 GP4 GP2 GP3 GP n (Independent) Consultants, GPs and nurses/ AHPs as partners?

32. Tackling the democratic deficit/ enhancing local control PUBLIC ENTERPRISE COMPANY/ COMMUNITY FT…? … MADE UP OF ‘MEMBERS’ ON GP LISTS…? Community services Non-PbR services Outpatients and diagnostics GP1 GP4 GP2 GP3 GP n (Independent) Consultants, GPs and nurses/ AHPs as partners? Integrated Care Record

33. Exploiting the GP registered list

34. FOUNDATION LEVEL TWO LEVEL THREE LEVEL FOUR Surgery Diagnostics Medicine HEALTHCARE COMMISSIONING PROSPECTUS General medicine, family medicine, continuous care Definitive differential diagnosis, specialised condition support Invasive work and exacerbation support Specialised services General Practice General practice, provider services, OP, diagnostics FT/ NHST/ IS Regional and sub-regional centres Regional and sub-regional centres General Practice ICO ICO + any willing provider GMS/ PMS Post-PbR PbR/ Post-PbR Specialised commissioning agreements Designation Function Present Future Funding Delivery

35. PACE OF CHANGE

36. GOVERNANCE PACE OF CHANGE 2009/ 2010 2010/ 2011 2011/ 2012 Memorandum of Understanding (Heads of agreement) Formal joint venture (new financial flows) New institutional framework Independent development partner?

37. CASE STUDY ONE: Results

38. Surgery waiting 2002 - 2007

39. Outpatient waiting 2002 - 2007

40. CASE STUDY TWO: Results

41. KS4: Best Results for at least 14 Years

42. KS4: Best Results for at least 14 Years Despite

43. KS4: Best Results for at least 14 Years Despite Being the least able year group on entry

44. KS4: Best Results for at least 14 Years Despite Being the least able year group on entry Having a massive level of mobility and disruption over 5 years

45. KS4: Best Results for at least 14 Years Despite Being the least able year group on entry Having a massive level of mobility and disruption over 5 years Only 20% being on target in September 07

46. Results better than top 25% of similar schools

47. Minimum KS4 Trajectory 2009 National benchmark

48. Minimum KS4 Trajectory 2009 Match national standard with least able year group National benchmark

50. New school plan initiated here

52. One set of problems solved…