CPIC Blog May 2019

If you were asking anyone about the decisions they make then most people may say that they don’t or more often rarely say they are in a position to make decisions. Yet we judge the performance of many people on the basis on the way we think they make decisions. To complicate matters somewhat we base the training and educating people in such a way as to place them in a position where they make good decisions. So, lets examine this in more detail. What is a decision? In the most basic of terms it is the way we connect the available evidence to a choice. It is a process that is at once cognitive and rational. It will also be strongly influenced by experience. If we were stick our hand into a flame we know its hot and risk being burned, we might only have to do it once to know that if faced with that situation a second time we will have the cognitive processes through what we call memory to know not to do it again.

If we rely upon others to make decisions for us, as we might if we are in a position to become reliant upon a professional carer to make decisions for us we are placing our trust in them to reduce risk to a point where we can ensure safety. Carers are therefore trained to make decision that have outcomes for others who may not be a position to care for themselves to ensure they are safe and their personal needs are taken care of. The problem however lies in two critical areas – that of how we assess and give prominence to the available evidence and our memory of past events that tell us there is one correct choice to make. During world war two, crews of bombers were highly trained to deliver their payloads to pre-determined targets, yet analysis of the results clearly demonstrated that effectiveness was limited – when human decision-making and interpretation of available evidence was examined the actual strike rate of bombs finding their intended targets was extremely low. The solution was to examine the ‘rational’ evidence available and then redesign the delivery process based upon a sequence of known inter-dependencies. This could be drafting into a sequence pictorially known as a flow diagram, linking one dependency against the next. The result was a process that came to be known as ‘critical path analysis or CPA. Each stage in the sequence outlined the ‘available evidence in such a way as the human interpretation of such evidence was offered as a given – indeed the results from the application of CPA did increase the strike rate of bombs finding their targets – the lesson here is that for the operator the memory involved in the process is inherent in the prescribed sequence, all the operator has to know is the sequence of stages and the inter-relation of evidence to make decisions and improve performance.

Now we might think we are pointing in the right direction, if we wish to improve the way that care is delivered to an individual all we need to do have a known set of inter dependencies made clear and remove the interpretation of evidence from the carer then we can ensure that a person requiring care is well served and satisfied. Here at the CPIC we are becoming increasingly concerned with this assumption that there is a best way, one that might be described as ‘best in class’ that will continually deliver the best for those for whom we deliver care. We have to go back and explore what we do when we connect thinking with doing. The most basic rational approach is clearly attractive, it is based upon past and known ways of doing things and assumes a form of standardisation of available evidence. Yet we if we apply this to larger scale data sources we know that we still have failures in the way that care is delivered even if we have contrary evidence that in lost cases the best result will be attained if we apply known solutions to problems. The risk we run if we do is multiplied by the fact that we can have multiple and conflicting data sources and a memory or cognitive process that is corrupted.

We are concerned with innovation and change, our basis is that even when CPA was applied there were many missed targets even though as a process it delivered better results than before but in a world in care were miss-application of systems has a profound impact upon peoples lives we must strive to re-examine and rethink decision making. To train in the best way known clearly makes sense but it will still have problems- we need to find ways to overcome the wrongful interpretation of information and data and challenge the fact that our cognitive processes can play tricks on us and find ways to better connect our thinking with our doing.

Since writing the copyright paper “Changing the very Nature of the Care Sector” in 2016 (Copyright Ian Briggs and Jeanette Phillips) four years have passed.!!!

Despite an overwhelming response in London to “Changing the System” are we any further forward….. is the fundamental question.???

It is also five years since the CQC Fundamental Standards of Safe/Effective/Responsive/Compassionate and Well led parameters became law.

Are we making progress… ??? are the services we provide REALLY what our clients want, or as time passes, may the clients want a different type of service.

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Mr B, a 89 year old gentleman is helping us with our research for improved services for older persons in the community; Mr B is a sound minded entrepreneur/businessman, who started his working on the 5th July 1948 in the newly founded NHS.

On arrival Mr B had caught a virus from his wife and his cough was persistent.

A discussion took place with Mr Bs wife and daughter (an experienced Registered Nurse), whether Mr B would like/need a Doctors appointment.

Mr B and his wife decided that he did not feel too bad and would be fine.

Mr Bs daughter works in research; and together with academic colleagues is trying to ”change thinking” in social care away from deficit based thinking to Strength based.

As part of this research we are looking if future clients would partake in a service promoting health and well being and peace of mind.

The new service being trialed is a “peace of mind service” where a qualified First Aider attends the Clients home to do basic checks and rule out any serious illness in Real Time.

It must be stated that this is not in any shape of form attempting to replace any Health Care professional/ Doctor/or Paramedic.

This service is to measure the impact, if people feel better “in themselves” knowing that this service is available;

People may find this new thinking quite different and possibly even threatening, however this is not the intention.

The overall objective is as follows:

Public Money may be saved if this thinking were to be upheld.
This may be deemed as a first step with people of sound mind taking responsibility for their own thinking and subsequent action.

Clients of the future may be interested in this type of service (recent research done by the CPIC in the South West of England have supported thus thinking).

Follow up Research.

Questions asked:

Did you find this service beneficial.
How did you feel at the time of the visit.
How did you feel a few days after the visit.
Would this type of service suit you as an individual.
Do you think this type of service has scope for future development.
Did this type of service make you feel confident for the future.

Answers to Questions: (feedback from Client).

Mr B fully understood that this was a new service being trialed and would be done in a CONTROLLED ENVIRONMENT (ie in the presence of his daughter who was a Registered Health Care Professional).

Mr B said he felt very reassured at the time of the visit, and it was the promptness and speed of the service which was impressive.

The interesting feedback came a few days after the new visit trial (namely five days after the visit). Mr B said the most important personal impact from the visit is that he felt confident, a lot of his peer group suffered from lack of confidence to manage their own conditions (Mr Bs own words).

He felt it was a boost to his confidence and immediately felt better, Mr B said he found the visit very reassuring, and personally he would find this service great value for money.

Mr B is normally enjoys good health and felt that this type of service with give him the confidence to carry on being independent (more saving to the public purse).

On discussion Mr B thought that this service would benefit the public sector in freeing up health and social care resources to be accurately targeted.

Mr B said that this type of service would definitely make him feel more confident in the future.

Conclusion: This is very seed stage action research; the objective being bringing Strength based thinking into practice in the community; Does it make a difference if so…. What difference does it make….

As a researcher( with a crisis is Social Care…) doing nothing is not an option…. Doing SOMETHING in a trialed controlled environment may be a STEP IN THE RIGHT DIRECTION OR….. A STEP TOO FAR…. (Depending on how individuals think/Who is right and who is wrong…..) . ONLY TIME WILL TELL.

Or….. Do we go round and round in circles doing the same thing over and over again and expecting different results ( Einstein/Definition of Insanity)……

A recent visit to Barbados in January 2020 was an interesting research opportunity to look at the health care system operating.

All Barbadian citizens are covered by Universal Health Care.

Barbados has eight polyclinics throughout the country providing FREE!!, 5 hospitals specifically for care of the elderly, and a network of child care facilities.

The main Queen Elizabeth Hospital is located in Bridgetown and has 500 beds.

This model services a population of 275,000 people on an island 21 x14 miles.

What was particularly interesting for me was the ongoing promotion of Health and Well Being through circulating magazines and even yellow pages.!!!

Every opportunity was taken to exploit heath education. And encouragement of self help and personal responsibility of health and well being.

What sprung to my mind immediately was this was a small island with limited physical space so a suitable “system” for balancing ill health and was imperative

It could be argued that being so close to the equator the citizens had all the benefits of the sun, however the “common sense” approach to balanced ill health and health and well- being was very interesting.

Also very interesting was there were available specific “care for the elderly” facilities, which would then free up the main hospital for turn round health care.

The island was clean and simple with a proud historic reputation of sugar cane being the main industry (interestingly sugary foods were few and far between).

Fish, chicken and rice was high on the food agenda…. The island is famous for flying fish..

Very interesting assignment ….. sometimes small islands produce great yields with Health and Well Being…

The Government is currently producing a Social Care Green Paper, which will consider a range of options to ensure our social care system meets the needs of our ageing population and is placed on a sustainable footing for the long term. This certainly reflects a change in thinking, by giving local authorities greater flexibility over the use of the council tax social care precept. This will enable councils to choose to raise extra money, while retaining savings from the New Homes Bonus, totaling £240 million, helping them to reduce pressures on the NHS.

The increases in funding, along with other changes will, I hope, help local care providers like Flexicare, give support to the most vulnerable. I wish Flexicare all good fortune in continuing to provide outstanding care.

Client Mr W is a 58 year old accountant whose career progression has been naturally sedentary and as a result the client got to a weight of nearly seventeen stone.

The client has a history of asthma for most of his life which progressed into COPD.

Also a situation was developing where the client was developing hypertension.

The client decided to take his health into his own hands are to develop a health and well being care plan which best reflected his needs.

Mr W decided that the first line of action would be to lose some weight, he diligently prepared weight watchers meals every day, and stuck to the portion size, every day Mr W did a two mile walk with his dog and started to change his behavior with regard to moving more when he wasn’t working.

The weight started to drop off and Mr W got very motivated and excited, taking echinasia to prevent infections of the chest he remained in good health.

As a result of such a committed positive attitude, Mr Ws blood pressure started to drop the systolic pressure dropped significantly due to a changed lifestyle.

This positive thinking created a win win, self fulfilling prophecy, and Mr W continued to go from health to health instead of problem to problem…

Is this a case of mind over matter (New Scientist /April 2019) or a commitment to break learned helplessness and take responsibility for ones own health…

Instilling this into future thinking could be a step on a new journey of thinking…. we can only try….

Flexicare UK Ltd are determined to change the way emergencies in the community are handled, we would love to assist the “One Gloucestershire” plan to keep individuals safe and happy within their own homes.
Recently one of our new Personal Assistants, who has worked for the Company for five months, has spent 20% of his time responding to emergencies, in his own time as a volunteer.
Purely by coincidence, the male Personal Assistant is a qualified FREC (First response Emergency carer/Level 4) and has a passion for building an emergency response service under the umbrella of Flexicare UK Ltd.
We think that is a fantastic idea, and wish to support Kirk for the following reasons….

By responding to emergency situations by a qualified practitioner, we may be able to prevent an unnecessary hospital admission

If emergency situations can be SAFELY handled by experienced Personal Assistants in the field, a culture of preventing hospital admissions will be born.

The client/patient will be more comfortable in familiar surroundings if a hospital visit can be prevented.

Finally it is more cost effective for the public purse to keep clients/patients at home of at all possible 

Also once an elderly client/patient gets admitted to hospital it is often difficult to secure a care/support package for the client to return home and this cost is then handled from diminishing public resources.
We are very excited about the “founding” of the Flexicare Flying Squad and hope that one day this type of working will become the norm in the community as we move towards the prevention/health and well being era of the future (Care Act 2014).

Towards the end of the 1990’s there was a great deal of political rhetoric about the cost and inefficiencies of a multiplication of agencies of state operating around the daily life of the citizen. By getting rid of this multiplication and streamlining through a ‘bonfire of the Quangos’ the citizen would be serviced by a much more efficient state and the by-product would be reduced personal tax burdens and more cash in the individual’s purse. This redesign as part of a ‘new wave’ of modernisation whilst it may have delivered certain benefits has failed to make much of a difference in other areas.

On closer examination it seems that one key facet of profound state redesign is continually overlooked – that of the mindset of the people of work within the system. There appears to be an assumption that if you relabel services, cut out intermediate agencies, introduce new policy themes with flashy business-like titles then staff will blindly follow and accept willing the changes made to their working patterns. The problem here is well known, ask anyone who has to manage major change in any enterprise, if you need to make a fundamental change to the way things are done then you need to make a serious investment in the people who are tasked with coping the day to day change. There are a few underpinning theories here that are worthy of discussion – lets take for example work that done some years ago that sought to understand why when a entire tranche of public service was redesigned and politicians felt that refreshed leadership was required to embed this change in large complex public institutions. The new leaders who were brought in (at great public expense) were to be ‘transformational’ , ‘visionary’ and ‘charismatic’ – the complete antithesis of the public administrators who has for years run these organisations. What the researchers ( Kakabadze et al) uncovered was these new imported leaders were so visionary they were immune to the day to day issues that staff were experiencing. The researchers coined the phrase ‘differential time’ to express the gulf that existed between the attention and agenda of the senior leaders and the remainder of the organisation.

The second important underpinning theory is that of ‘patterned behaviour’. Put simply people like certainty and predictability. If that sense of predictability and certainty is disturbed and tomorrow looks less attractive than today then many people will act each day as if it were like the day before and will resist the less attractive, less certain and unpredictable condition they are being driven towards. What is perhaps quite astonishing is that patterned behaviour theory suggest that it is for many a totally unconscious process. So, if we couple this less than effective leadership condition with the condition of passive resistance to change we have a recipe that begins to explain why still have multiple organisational boxes, strong fortress like identification that many staff have with the immediacy of the surrounding organisation or profession and a frustrated government still trying to address the frustrations of citizens who find it near impossible to understand why we have public services that make little or no sense to them.

There are however examples of where this is changing – and it is not changing because the agencies of state are changing it – it is because there are leaders and non-traditional thinkers who are just so bloody minded they are forcing changes through sheer force of personality and through frustration that we are continually repeating the mistakes of decades.