Wednesday, 28 March 2012

Dementia: Measuring Up

Dementia is in the news this week, with the Prime Minister’s challenge issued on Monday. It includes some sound principles and interesting ideas, but also has echoes of political headline-grabbing - the kind of initiative that may be old news by the time this blog appears two days later.

The old maxim “What gets measured gets done” must apply here. The difference between real change and empty rhetoric is whether, say five years hence, we will be able to look back and say yes, things really have got better. So what measures of success does the challenge include to demonstrate this?

Well, the Dept of Health paper mentions a lot of input measures: funding for research, care and other initiatives. But these just count money spent, not whether it does any good. Plenty of actions in there too, and some output measures such as the levels of diagnosis and the number of PCTs offering specialist memory clinics. But again, how much actual difference will this make to people's lives?

Only at Annex 2 do we find any real outcome measures, in the form of eight statements that express the aspirations of people with dementia. Fine as far as it goes; these are real outcomes that if achieved will mean real improvement.

But I see two problems: firstly these outcomes focus just on the person themselves. Very important of course, but surely 550,000 carers deserve a mention too – how will their quality of life (not just their ability to care) improve? It’s also disingenuous to imply that long-term cost savings aren't part of the agenda as well, through more research and better community support. What return on initial investment is expected here?

My second concern is that we may have a measure without a metric. If these aspiration statements are the outcomes, how well are they achieved now and how will we measure progress? The Alzheimer's Society conducted an excellent survey earlier this year, but their questions don't directly match the Prime Minister's challenge and it's not clear if/when the survey will be repeated. The National Dementia Alliance also describes seven outcomes in its 'Call to Action', but again these don't quite match the Prime Minister's challenge.

So frankly I’m not convinced. I’d like to think (as a carer) that things will change but unless we can establish and track some consistent outcome measures then I fear that history will repeat itself. In a few years time another strategy/initiative/challenge will come along to grab the headlines (or votes, depending on timing), and we’ll be in a very similar place again.

I really hope I'm proved wrong.

Check my web site at for more information and ideas.

Thursday, 1 March 2012

NHS: Public or Private?

Previous blogs have voiced my frustration at NHS inefficiency, and questioned what we are trying to "save" in the context of the NHS Bill. This doesn't mean I support the Bill; this blog looks at its implications from a performance management perspective.

Current focus may be on the NHS but this is just the latest of many government initiatives (CCT, Best Value, CAA, NHS Modernisation) aimed at bringing some private sector motivation and efficiency into public services. If you believe that the public sector is inept, inefficient and incapable of change, then something radical has to be done to control spiralling costs. Commissioning plus direct private sector (and third sector) involvement  is one way to do this.

The counterargument is that private sector organisations will prioritise profit above care, ethics and anything else that matters to the NHS, hence equality of access and standards of care will fall.

Of course, neither of these stereotypes is true for these sectors as a whole - although it's never hard to find striking examples of each. But it's equally possible to find great examples of innovative improvement in the public sector, and outstanding examples of care from private providers.

From a performance perspective, I don't believe there's anything inherently 'bad' about either the public or private model. It's as much about mind-sets as mechanisms, and a carefully-constructed performance framework could support this by demanding the right balance of clinical, financial and patient-based outcomes. So for examples, private providers would have to demonstrate their ability to deliver equitable services as judged by patients, and that they don't just cream off the most profitable business. And those in the public sector would have to demonstrate an ability to manage within plausible financial limits, and that they don't view the NHS as a bottomless pit of money.

My real reservation with the Bill is one of transparency. As others have commented, it seems to allow the Government to make future budget cuts without being accountable for any consequent reductions in service. Whilst it could be argued that this is a further stimulus for greater efficiency, experience suggests that few organisations have the capability and maturity to respond in this way. It's much easier just to make cuts and blame someone else.

What we need is honesty about money and honesty about the outcomes - community as well as patient-based - that we want to achieve, together with a transparent framework that captures these outcomes. And then have everyone working towards those goals.

Check my web site at for more information and ideas.