Q&A with Sir John Oldham
Sir John Oldham, a general practitioner, is regarded as one of the world's leading experts in large system change, having practical experience of training teams to do this in a number of countries. His passion is, with others, to help make healthcare safer, more reliable and efficient.
As part of Integrating Care's senior advisory board, we picked his brains in a Q&A session, which appeared in the print edition of National Health Executive (July-August 2014). Thanks go to the editor, Adam Hewitt, for his kind permission to reproduce the article here.
Q and A
You’ve been making waves recently, with the publishing of the report of the Independent Commission into Whole-Person Care, which you chaired. If you could only pull out one key suggestion from your report, which either this or successive governments should take on board, what would it be?
The whole emphasis of the report is that there isn’t just a single thing to do. Previous failures at reform have fallen into that trap of focusing on structures. It is about creating the environment that fosters the right relationships and behaviours. That means tackling how people work and are trained, aligning financial incentives, ensuring information flows happen, ensuring policy generation and regulation are balanced between the different sectors and aligned, and that publically funded research is where we need it to be working. Most importantly, embracing the users of the system as part of the system - in other words, tackling the issue from multiple directions.
What do you see as the current major barriers to co-ordinated care?
In short, mindsets and vested interests that prefer the status quo. This is not mendacious but anxiety about change. The more examples we create, the easier we can make the case and the lower the barriers become.
Where have you seen the most progress in implementing a whole-person care model?
There isn’t just one place but a number progressing on different fronts. For example, NHS Kernow and Age UK are engaging citizens meaningfully and showing how that improves outcomes and lowers admissions; Leeds and Manchester have their transformation programmes; Kent has comprehensive integrated teams; Greenwich; Lincolnshire – I could go on. Looking overseas, there’s Sweden, Alaska, Ontario, and some of the accountable care organisations developing in the US.
What do you think will be the biggest challenge in making the transition from local co-ordinated care initiatives to integrated care at scale?
Again, there isn’t a biggest challenge. The spreading of integrated care will come from setting the policies that push the system in a particular direction, combined with giving head room and air cover to people to implement change within a planned financial framework.
You are, of course, an experienced GP yourself. How important do you think the role of primary care will be if integration plans are taken forward?
Very. But primary care will also have to change and be different, for example in the way people access services, the range of those services offered collectively in a locality, and the skill mix of people involved. I expect the walls of institutions in both primary and secondary care to be more porous. Most will rise to that, some will not and may get left behind.
You have been outspoken in your belief that a disease-specific approach will only undermine the NHS, and services must therefore adapt to meet the changing needs of a changing population.
I am simply reflecting the mathematics and the majority need of those using health and care services. A Monty Python-esque queue of separate teams dealing with bits of people is poor care, more prone to errors, and inefficient for the system. This is not about diluting specialist input but pooling specialist knowledge for the bespoke benefit of an individual.
You have worked in education as well as in health and care. Do you think the models you espouse are applicable to other services and businesses also?
Some of the models I espouse come from other areas. For example, for many years I have argued that the formal buddying arrangements that have existed between well-performing and troubled schools is one we should use in healthcare, and I am pleased to see that beginning to happen with hospitals.
The most successful organisations in any industry or sector are those that systematically look outside themselves and are open to adapting ideas for their own solutions. At a time when the world is changing fast the willingness to do that becomes more important.
Those organisations and individuals who adopt a “not invented here” mentality will stagnate and fail. In health and care that means they are letting down the people they are striving to serve.