Books

The Birmingham East and North Primary Care Trust (BEN PCT) and Heart of England Foundation Trust (HEFT) are to be applauded for their work. Their efforts have not only tremendously benefitted their community but, indeed, inspired providers around the world. The fact that they accomplished their work not in a homogeneous, middle-class, white neighbourhood but in an urban, multicultural community with significant socio-economic disparities makes their achievements all the more remarkable. The successes of organizations such as Kaiser Permanente are often discounted because of the belief that they ensure the well-being of only a select segment of the population. A community like Birmingham, England, is truly reflective of our emerging multicultural world, thus making it a highly appropriate testing ground for new models of healthcare delivery.

The success of any group of providers in meeting community healthcare needs is clearly not just about structures and governance. Though structures and governance are important enablers for success, perhaps more significant is the alignment among providers and the leadership that is in place to make it all happen. The successes of BEN PCT and HEFT emanated from a clear alignment around the single goal of improving the health of their population. This common goal drove these organizations' priority-setting activities and their bold implementation of multiple initiatives.

Alignment is critical because every individual, no matter how humble, needs a picture of what constitutes success, and multiple leaders with unaligned notions of success are unlikely to achieve a common goal. BEN PCT and HEFT have never strayed from their vision - a vision that is clearly shared by individuals at every level of their organizations.

The relationship between BEN PCT and HEFT to some extent parallels the relationship between hospitals in Ontario and the new, evolving structure of Local Health Integration Networks (LHINs). The success of LHINs will also depend on all their constituent organizations embracing common goals and creating shared definitions of success for the LHINs' leaders. At present, a cynic might say that if success does happen, it will be by accident. A more optimistic view would be that Ontario can achieve some of the same successes realized in Birmingham, but it will take a great deal of time and may be at great financial expense.

In Canada, the issue could be that, in contrast to the National Health Service (NHS) in the United Kingdom (UK), we are too timid in our approach to breaking down the status quo. Throughout its history, the NHS has been known for its courage in making radical changes in its attempts to "get it right." How, in Ontario, can we be driven by a common goal of improving the health of our population when crucial pieces remain outside the health system? These pieces include structures such as public health and primary care. The former independently performs the vital function of monitoring the population's health status and the latter is not only outside the world of LHINs but also external to the domains of most integrated health regions across Canada.

The effective and strong working relationship between the chief executive officers (CEOs) at BEN PCT and HEFT is another factor that was paramount to the success of their ventures. Such relationships are built on trust, mutual respect and common goals. Although the two CEOs headed organizations that each played a different role within the system, the lesson to be learned is that having a common, driving and overall goal and a shared picture of success was indispensable and helped to ensure the achievability of their joint vision. The same structural and governance relationships obviously exist in other communities throughout the NHS. However, the incredible success of these two organizations clearly points to the role that their leaders played in making it happen. The case study in this volume not only highlights the strong goal orientation of the individuals who led BEN PCT and HEFT, but also the complementary nature of the styles and skill sets of those two people. For health system boards, this element highlights the fact that interpersonal compatibility is far too important to leave to chance when recruiting a new CEO into a community.

A respectful relationship is underpinned by the belief that the other individual is competent in his/her role. For several decades in the NHS, an individual's career success was defined by the ability to climb the corporate ladder within the system's regional structures. To some, the poor performance of many of the NHS's institutions was tied to the reality that the regional structures continually drained the most talented people away from those institutions. The concept of foundation trusts was established, in part, to ensure that healthcare administrators could be recognized as having successful careers by remaining in one institution and achieving success in that role. The innovation was also intended to create an incentive reward system for institutional success. One cannot help but wonder if, a decade or two down the road, Canadian provinces will take a long look at whether the concentration of senior executives in downtown office towers has had an impact on the experience and capability level of those remaining behind to lead healthcare institutions.

The creation of foundation trusts was also a clear signal by the NHS that competition is good. In the case study we read that HEFT "operates as a large healthcare enterprise, intent on expanding its market share to include more patients in the region." This phenomenon is particularly worth watching when one realizes that in a public system we have a closed, zero-sum game. If HEFT is to acquire a greater market share, this will come at the expense of the other hospital providers. The other possibility is that HEFT hopes to draw activities away from other primary trusts in the Birmingham area. This approach would be consistent with the commercial imperative that a business must always grow to remain competitive. It was most refreshing to hear about an organization that is clearly strategic in its thinking. What may be most worth watching is the impact on other weaker organizations funded by BEN PCT and their response.

The BEN PCT and HEFT case study is rich with exciting new ideas and concepts that have widespread applicability in numerous communities across Canada. I was particularly interested to note the comments regarding physician engagement. One frequently hears arguments that progress in Canada is inhibited by the fact that the vast majority of our physicians receive their compensation by way of fee-for-service payments. The case study dispels the myth that, in a salary-based system, physicians immediately buy into change. The authors make clear that in all change initiatives physicians - no matter how they are paid - must be brought in as full participants to help define the outcomes and the change process itself. I do not intend my observation here to mitigate the reality that Canadian healthcare has a long way to go to achieve alignment between the goals of practicing physicians and our healthcare system in order to achieve better overall outcomes. Indeed, the case study also emphasizes the need for long-term commitment and perseverance through the change process.

I was also interested to read of the increasing acceptance by physicians of the expanded role of other non-physician healthcare professionals within the BEN PCT and HEFT system. The UK has often been thought of as being very traditional in terms of physician tolerance for expanding the roles of other healthcare professionals. It would perhaps be useful to explore this changed reality relative to the progress that has been made in North America.

BEN PCT and HEFT have fostered learning environments and created unique settings that support the skills development of their staff members. HEFT's creation of its own "Lean academy" is indicative of the supportive environment that organization has developed in order to grow the skills its front-line staff require to lead change. The NHS is to be applauded for the ongoing refinement of the various think tanks that have been piloted in search of new best practices, the latest being the NHS Institute for Innovation and Improvement. Canada's healthcare providers would benefit from similar kinds of structures. One always wonders whether the provincial nature of healthcare delivery in Canada detracts from the ability to muster the necessary critical mass to assemble such resources. This is perhaps a role the federal ministry of health could take on and fund for the country.

All 10 BEN PCT and HEFT projects given as examples of improvement initiatives would be beneficial in almost every Canadian setting. Indeed, some Canadian jurisdictions have already undertaken initiatives similar to the ones in Birmingham. For example, BEN PCT and HEFT's focus on projects related to chronic disease management is in step with many comparable Canadian endeavours. It would be interesting to conduct an in-depth comparison between the outcomes achieved in Birmingham and those realized in similar Canadian communities. This could include projects involving chronic obstructive pulmonary disease, diabetes, home hospice services and elder care assessment.

Clearly, Kaiser Permanente played a significant support role in mentoring BEN PCT and HEFT staff members. It is heartwarming to see the strength of the bond that has grown between these organizations that are physically an ocean apart. I hope that both Birmingham organizations will now commit to mentoring others throughout the world. Their success demonstrates that the concepts that have made Kaiser so influential can be applied in other systems that have different structures, forms of compensation, kinds of governance and even political ideologies.

Again, the success of BEN PCT and HEFT must also be labelled as extraordinary, particularly in light of the reality that it occurred within one of the world's largest bureaucracies. The NHS's at-times stifling bureaucracy is legendary. The Birmingham leaders nevertheless persevered, broke the rules when needed and sometimes even got the rules changed. Most obvious of all, they remained focused on their goals and found ways to overcome the hurdles in their way. It is again a tribute to the NHS that it is emulating a learning organization and allowing its institutions to learn and change the rules. Such flexibility is seldom easy in large government bureaucracies that are all too often entrenched in regulations and red tape.

NHS organizations have had much longer experience than Canadian institutions in reporting a multitude of indicators to meet government accountability requirements. It was encouraging to read in the case study that this process is being streamlined in the UK in order to achieve purposes that are more useful and relevant at the local level. I hope that Canadian institutions will not have to endure the same arduous journey to arrive at a sensible solution.

Perhaps missing from the case study, other than brief mention among the appendices, is any reference to the use of information technology (IT) strategies as enablers in the achievement of BEN PCT and HEFT's initiatives. I expected that in lieu of discussing the purported huge investments in creating integrated IT systems, more mention would have been made of their benefits. Perhaps this has not been one of BEN PCT and HEFT's success stories.

The citizens of East and North Birmingham are obviously well served by providers who are truly committed to the goal of meeting their community's healthcare needs. They enjoy a system in which multiple providers have created an alignment of goals and in which healthcare leaders have demonstrated that they are more concerned about deliverables than protecting their turf. Staff members of both BEN PCT and HEFT truly deserve the recognition they have received for their accomplishments in healthcare delivery. There is little doubt that Canada and the world will learn a great deal from their willingness to share their experiences.

About the Author

Murray Martin, President and Chief Executive Officer
Hamilton Health Sciences