I knew it would come eventually, but still, it doesn’t make it any easier does it? My last week on this project was here – and the dreaded handover before I went back to my day job.

On Wednesday of that week I held a stakeholder event, the last one I’d be involved in.
I designed the agenda so although I would lead the morning session, I could symbolically hand over the afternoon session to my successor Barry. He has the enviable task of taking my ‘baby’ away from me and managing the implementation phase. It wasn’t planned but the room we ended up using for the event fitted the occasion – we had to present from a stage and it felt like my curtain call.

I passed all my new friends and colleagues over to Barry, the new NHS Leicester City stroke redesign lead. Those stroke survivors, their carers, the clinicians and social care staff who helped me to find my service improvement wings said goodbye, gave me flowers and hugs and made me well up inside. They all wished me good luck for the future. 

On Thursday, I packed up my project office. I took the pathway pictures down off the walls, threw out the residual ‘focus session’ biscuits that had gone soggy and well past their sell by date. I unplugged the computer, loaded the car with boxes and bags and pulled down the blinds. I said goodbye to the GP practice staff who have been so welcoming and drove away.

I could feel the ties being severed, one by one. Then as I made the journey back to the offices of NHS Leicester City
I reconnected. 

On Friday I was back at NHS Leicester City’s headquarters. I walked into my office and felt funny. People were saying hello and I wasn’t quite listening. I was making notes about all the things that had happened while I had been away, what I needed to know about the in-year financial position, how the 2010/11 financial plan was developing and what our strategy was to move into the final year of NHS growth money.

Yes, I reconnected but I haven’t forgotten what I learnt from my secondment. I have had the most exhilarating experience and been lucky to have been given the time to do something so out of the box. My secondment gave me the opportunity to remember what it is about the NHS that is so important and why I am here – to serve patients. 

In the days since I arrived back, I have acquired a massive energy. I have not stopped seeing patients in everything I do. I find myself visualising individuals I met as I think about our overarching work, for example what will balancing the financial plan mean to Jaswant or what might staying true to our health economy financial strategy do for Linda? I have not stopped asking if there’s a more effective way to do this money stuff that might release more resources to help.

That’s how I have reconnected and I have the redesign project and all those stakeholders to thank for it. I am so excited about being back and making the best use of all these new skills I have acquired and all these new connections I have made – in a time when I will need all the enthusiasm and tenacity I can muster. Oh, and rest assured, I will make sure we get our new stroke pathway.

It’s cold, it’s damp and it’s wet. But this project is still giving me reason to be cheerful.
 
During one week recently, getting towards the end of my project, alongside core members of the stroke redesign project team, I visited a community stroke service demonstrating the kind of model we want to introduce across Leicester. A dedicated group of 10 of us boarded a minibus in the early hours to journey to Portsmouth.
 
We were enthusiastic about what we’d be able to see in action and what we’d be able to learn to ensure the success of our service improvement. And what sheer inspiration we found when we got there.
 
We talk about needing clinical leaders in the NHS to help secure our longer term sustainability in the leaner years to come. Well we found one here. Nothing was too much trouble for this lady. She led, inspired, challenged and supported her team. A real ‘can do’ approach enabled her to push the boundaries of continuous service improvement and challenge more traditional thinking on managing clinical risk.

Applying an ‘in-reach’ model, her mantra is: ‘Why is this person in hospital?’ She is motivated by the day’s operational problems and her energy levels were constant. We were more tired from asking a multitude of questions on how the service worked than she was answering them.
 
This ethos has enabled her to improve local health outcomes for people with stroke. She’s reduced readmissions and reduced the numbers and intensity of residual social care packages. Patient and carer satisfaction levels have never been higher. The approach has resulted in reducing costs and a seamless service for stroke survivors and their carers as both health and social care needs are provided at the same time by the same people. Her management style asserts continual learning and empowerment. Her passion will ensure that the team never falter in their drive for improvement.
 
By the time we got back on our minibus for the long journey home, the commissioners among us were ready to change the world. How exhilarating to spend the day with a clinical leader who has it all and the ambition to achieve even more.

One of the objectives of my redesign project has been to demonstrate improving quality can be achieved at the same time as reducing expenditure. Not an aim for the faint hearted, but one that we all know is now absolutely fundamental to the way we develop NHS services in the future. In fact, my business case was submitted and approved on this assumption, so it’s crucial I keep a grip on this.

The field work I have carried out over the last few months supports this assumption. There is a strong correlation between more intense, stroke specific, rehabilitation that is given in those early days and the reduced amount and complexity of longer term residual social care support. My work with patients and their carers has also reiterated their aspirations for being able to live more independently again, making the most of opportunities to do things for themselves.

If I am to make this redesign happen, I need to find a way to secure savings that will arise further along the stroke care pathway and use them to help pay for the increased therapy input required in those early days after stroke. This is a great opportunity to work jointly with social care colleagues to look at how we might pool our time and money resources to get a better fit with a much bigger impact.

Leicester’s social services have been really supportive of the stroke redesign project so far. This is when that support will be tested. We have started talking through the practical considerations we need to think about if we want to use savings to fund costs upstream. Also on the agenda are options to transfer data from health to social care information systems, the possibilities of joint rehabilitation assistant posts that can bridge the health and social care divide, and how formally pooling our financial resources might be the best approach to achieve this redesign.

I have been so impressed with the enthusiasm of my social care colleagues to work with me on this. The door to joint commissioning is wide open and we should be taking every opportunity to walk through it and get the biggest impact we can for our pounds spent. I know it will be tricky once we get down to the transactional detail of making it happen. But if we are clear about our aims then we are all agreed those details can be worked through. 

In the end, six months of work came down to one meeting. Anyone who has ever done an exam, driving test or job interview will know how I felt before the business case approval panel.
 
One little moment in front of the ‘powers that be’ would decide whether the redesign of the stroke pathway went ahead. It didn’t matter that my secondment was nearly over and it won’t be me who implements the project. All I could think about was how much I wanted this to happen and the hopes and expectations of the stroke survivors, carers and clinicians who supported every step of this process.
 
The decision on my business case was in the hands of NHS Leicester City’s commissioning executive, a heavyweight group of senior managers and practice-based commissioning clinicians.
 
I’ve spent many years on their side of the decision table. I was good at listening and had a nice line in challenging interjections like, ‘so what?’ and ‘but what if?’ Perhaps that’s why I spent hours thinking about the questions I might get as well as worrying about the answers.
 
I confess being on the other side is, well, scary. Sleep didn’t come easy during the nights leading up to my 20 minute slot. Then, when the day came and I was finally in that room all I wanted to do initially was take the director of finance’s cosy seat opposite mine.
 
Instead, I took a deep breath and relayed my prepared speech. I even got up and drew on the flip chart to illustrate my points, a bit of a trademark for me. Then I reasserted the caveats I believe are essential to this project. Those caveats are that we properly resource the implementation phase; reduce cost at the same time as building better quality; and work across organisational boundaries. I outlined how the next bit of the redesign will happen and asked if there were any questions (I’m always so polite). Then I waited.
 
I held my breath until they said ‘yes’ and I replied “Yeesssssss!”. It was a ‘yes’ to moving on from my secondment, knowing the project can continue. It was a ‘yes’ on behalf of more than 50 patients, carers and clinicians who formed my project group. And today, most of all, that` ‘yes’ was an endorsement to leaving my comfortable executive chair (and comfort zone) and putting myself in the do-er’s shoes. I slept like a baby that night.

I have just had a lesson in finding the right pace. I scheduled an extra event so I could work with our stakeholder group on some of the finer detail of the redesign – at a speed to suit them. It was worth changing my plans and boy, what an event it turned out to be.

We spent the day looking at the option appraisal for the redesigned stroke service that will be implemented across Leicester. There was an exceptional turnout (this was the fourth day we have spent together) reflecting a really good mix of stroke survivors, their carers and health and social care staff.

I can honestly say that the day was a complete inspiration to me. It was definitely one of the best days of the whole project so far. It was stakeholder involvement at its best and I ended the day thinking just how robust the option appraisal for this redesign is as a result. So, what was it that made it so special?

At the heart of its success was its simplicity. We went through evaluation criteria, weighting the criteria, and got that all agreed. We described options, compared and contrasted them so that everyone was clear what the similarities and differences were between them. We scored the options using the criteria and we covered the risks associated with our options. We had a clear winner in terms of benefits score.

Maybe the agenda doesn't sound all that simple, but the other critical success factor for me was that we spent the whole day on it. We took plenty of time to get it right. We applied a very methodical approach to what can be quite a tricky concept and when someone on the stroke survivors' table said to me ‘Oh, so that's why...’ and a second person then added  ‘Aah right, I can see now why you ....’ I knew we were taking everyone along with us.

Not only have I learned a big lesson from this project, but I have seen it in action. Take the time to think things through, give others the time to catch up and then together you can find the best solution.