Healthcare challenges 30 years on

Royal Wedding preparations and hype are reaching fever pitch here as street party and private celebrations are in the final planning stage. I have the champagne on ice, have recovered from the fact that all major supermarkets have sold out of smoked salmon and am, as usual, struggling with the bunting. This is an occupational hazard when you are only five foot three inches tall and live in a very old house with very high ceilings!

As I pause from labouring in the kitchen, I have started to reflect on life when the last major Royal nuptials took place, Charles and Diana’s wedding in 1981.

In those days I worked for an independent hospital chain, who had recently invested in a maternity facility in Windsor in the hope that any Royal offspring would be born there. One can imagine how disappointed they were when a year later, William was born in an NHS hospital in London.

At the risk of sounding like an old fogey, of course so much has changed in those 30 years. In 1981 there was, I think, one MRI scanner in the UK. Fast forward a generation and over 1 million MRI’s are undertaken every year in the UK.

Twice as many people can now expect to live till they are 85 but half as many will die from coronary heart disease.

Five times as many are now obese but there are 30% less smokers. Male obese smokers are still at a high risk of having a stroke but the death rate from stroke has reduced from 120/100,000 per population to 22/100,000.

And so the healthcare merry-go-round goes on. We win one battle, another rears it’s ugly head. As we improve survival rates from coronary diseases and stroke, we face chronic disease caused by unhealthy lifestyles.

We still face the same challenges – expensive innovations that increase survival rates and improve the quality of life, the costs and logistics of delivering care and the sustainability of any solution.

Two other things haven’t changed since 1981. There is a massive team of dedicated doctors, nurses, carers, therapists and let’s not forget some managers too – all working through the bank holiday to deliver excellent care in hospitals and the community throughout the UK. And please spare a thought for the London A & E departments and emergency services. coping with a huge influx of visitors to the capital.

The other? My party will start early and end late – just like 1981.

What do patients really want?

‘Nothing about me without me’ is one of the core messages of the planned NHS reforms with the aim of ‘putting the patient at the heart of everything we do’.

But what do patients REALLY want? I suspect that no amount of market research or in-depth questionnaires could give a definitive answer as we are all individuals with a varying combination of needs and fears. This list is my attempt at summarising what those of us associated healthcare should be considering for our patients.

Information: This immediately brings us to dodgy ground. How much information? Information about diagnosis, treatment options, prognosis – the list goes on. But a fundamental principle should apply in all cases. Take your lead from the patient and their carers. Some patients want to know everything – from the gory details of surgery to recovery statistics. Others are happy to trust their medical team and really would rather not know any detail. Clinicians are now beginning to accept that patients will search the internet for answers and may often miss the point so time must be taken to give them the right facts.

Choice: But how much choice? I have spoken to many patients who like the thought of having a choice of hospital and treatment but ultimately find too much choice burdensome. With choice must also come education and how much time is available for this? What about the ability for patients to take on board the information needed to enable them to make an educated decision? Patients would normally opt for a hospital nearby for surgery – or prefer to go to their GP practice for a day case. But what if the centre of excellence is a hospital further away, or the practice has little experience of providing procedures? Choice can, in some cases have a detrimental effect on the patient so must be carefully handled.

To be listened to: Tears of frustration among patients and carers are so often the result of the feeling that they are not being listened to. I would love to see listening skills and communication skills included in every continuing professional development programme for all patent-facing staff.

Easy access to GPs: Patients want to see their GP on the same day if there is a cause for concern. Good practices keep a limited number of daily slots for semi urgent consultations. Other good practices have a ‘turn up and wait’ system where patient understands that they may have to wait a few hours but they are guaranteed to see a GP that day. That’s what patients want. Effective diary management at primary care centres will have an instant impact on reducing emergency department traffic.

Decent out of hours primary care cover: Good telephone advice or a night time home visit by a GP reduces patient anxiety and of course improves patient outcomes. A basic, fundamental requirement that is delivered with horrifying variations of quality.

Continuity of care:  The care for patients with long term conditions to be coordinated by their GP to be cared for in their community. (This has been added to my list as suggested by @mellojonny)

Clean hospitals: Spotlessly, measurably, consistently super-hygienic is what patients hope for but don’t always expect. This must be the norm.

Courtesy and kindness: My grandmother used to say ‘a little kindness goes a long way’ And it does. However busy, stressed, overworked, underpaid or generally grumpy a doctor/nurse/porter/therapist/receptionist is – they are working in an environment where people are often in pain, upset or frightened. They deserve to be treated with respect and care. Always.

Parking or easy access to public transport: This is a constant cry of patients and their carers. So often a stoical relative will finally crack as they drive around a hospital or health centre car park desperate for a parking space.

Reduced waiting times for procedures and fast track appointments for suspected cancer diagnosis. Of course that’s what everyone wants.

And finally – a matter close to all our hearts…

Decent hospital food and someone to help frail patients eat: The heartbreaking stories of elderly patients unable to feed themselves becoming malnourished in hospital must stop. Good food improves patient morale. Hospital food is nearly always high on a patient’s wish list.

If our health system can address all of the above – I think we will have pretty much cracked it!

All incapacitated are equal – but are some more equal than others?

I have no doubt that our Prime Minister is an intelligent, caring and well meaning person. I believe that many of the Tory policies have some merit – any party, coalition or not – would be facing a torrid time right now. One must also acknowledge that being in opposition must be a comparative breeze – easy to criticise and not so easy to come up with alternatives.

But somehow David Cameron seems to get it wrong whenever he talks about welfare or the NHS. It may be that his words are badly reported – but surely a decent spin doctor could have foreseen the outcry that would follow the PM’s statement today on alcoholics, drug addicts and the obese.

Apparently there are currently over 81,000 people claiming benefits, citing alcohol or drug addiction or obesity as the cause. Cameron stated:

"We are finding a large number of people who are on incapacity benefit because of drink problems, alcohol problems or problems with weight and diet. And I think a lot of people who pay their taxes and work hard will think: 'That's not what I pay my taxes for. I pay my taxes for people who are incapacitated through no fault of their own.'"

So – with one bold stroke, those battling addictive disorders have all been tarred with the same brush. No-hopers who are leaching on society and use us poor tax payers money for their next fix, drink or bag of chips. Oh if only life were that simple. If only an addict could say – OK that’s it now – I’ll stop. If only someone battling alcoholism could schlep up to an interview and treated with the generosity of a job offer.

Many addictive diseases are ‘through no fault of their own’. They can affect people suffering from genetic predisposition, social deprivation and all manner of psychological factors that the layman would not understand.

But Cameron’s statement hits at something far more basic. Many millions of people treated in the NHS are suffering from conditions or events related to their conscious lifestyle choices. At what point does a lifestyle choice become an addiction? At what point does a momentary, but catastrophic decision (such as jumping a red light) made of free will, negate the eligibility for support and care?

What about the estimated £5 billion a year something related illness costs the NHS? Every single one of those smokers made an active choice to pick up that first cigarette. Chronic pulmonary disease is an expensive long term, chronic condition, let alone the many smoking related cancers that require surgery and ongoing treatment. And how about the careless driver who causes dreadful injury to himself and others? The spinal units have their fare share of unfortunate, but innocent people who have fallen off their horses or motorbikes – their choice of activity, but probably not their fault.

I am much more interested in the benefit cheat who is happily and healthily working cash in hand while claiming incapacity. As a tax payer – I seriously resent those payments.

If we are to continue to be a caring ‘Big Society’ – we must protect the weak, the vulnerable and the ill, whatever causes their ailment.

Unfortunately, with this recent statement, Cameron suggests that those who may have some responsibility towards their illness or disability should not qualify for help. I will try to avoid chocolate overload at Easter or that extra glass of bubbly as I watch the Royal Wedding – otherwise I’m not sure that I would pass his test of worthiness.

The NHS Future Forum – my dream team.

I felt quite encouraged when I visited the Department of Health Website to view the list of people who will make up the NHS Futures Forum. A worthy mix of clinicians, hospital and community, chief executives from Acute Trusts, the voluntary sector and local councils.

My bonhomie was slightly dented when I read the brief for the forum:

‘…..will oversee the NHS listening exercise.  It will drive the process of engagement with staff, patients and communities over the coming weeks. …. The Forum’s first task will be to report to the Prime Minister, Deputy Prime Minister and the Secretary of State for Health on what they have heard’

Mmmm – there is such a thing as selective deafness so I can only trust that what is heard will equate to what is being said. There is a danger that this group is a toothless tiger. The forum needs to have some real clout in persuading the government to create a workable version of the Health and social Care Bill and not just tweak a few headlines.

If only there could be some way we could co-opt a few extra members to the forum. In a perfect world where time travel would be needed for some of my nominees – the following would be my choice for the leading lights of this ‘engagement process’

Florence Nightingale: During the BBC question time debate, a panel member said ‘where is Florence Nightingale when we need her?’ Yep - we need you now Florence.

Albert Einstein: No-one could pretend that rescuing and re-working the reforms is going to be an easy process so we need a sharp mind on the job.

Joseph Lister: The father of antisepsis. Some hospitals still need to clean up their act.

Claire Rayner: Nurse, journalist, agony aunt and patient advocate supreme, who left this message to be issued after her death last October ‘Tell David Cameron that if he screws up my beloved NHS I’ll come back and bloody haunt him’

Aneurin Bevan: The founder of the NHS – to make sure the forum remembers the basic principles of the state provision of health.

Henry Kissinger: Negotiator and diplomat – perhaps he could apply the skills he used to pioneer détente between the US and the Soviet Union to ensure peaceful and constructive discussions.

Lord Robert Winston: Professor, Medic, Pioneer and highly intelligent commentator with a non confrontational, level way of voicing his opinions with exceptional eloquence and good sense.

And finally..

David Cameron: First hand knowledge is so much more powerful than diluted, rehashed second hand reporting. He can listen for himself instead of hearing someone else’s version of the forum’s views.

If only this dream team could renegotiate the re-working of the NHS reforms, I think that I, and probably many more, would feel a lot happier as the ‘pause, listen, reflect and improve’ process continues.

Think positive

As it’s Friday, the weekend has started and the blossom on the trees carries a promise of Spring I have decided to write a positive blog about the state provision of health in the UK.

I’m a great believer in Karma so I’ll try to bank some good luck by sending kind thoughts to the poor beleaguered Andrew Lansley. Being UK Secretary of State for Health right now must be feeling like carrying the worst type of poisoned chalice.

But of course it didn’t need to be that way. If consultation had really meant a two way exchange of views and listening meant hearing and then acting accordingly, we may well be on our way to some sensible, cost effective changes in the way care is delivered in the NHS.

A little unkind maybe, but highly amusing anagram of Lansley’s name is ‘ensnared wally’ (courtesy of @furrycanary).

So Mr Lansley, to avoid that moniker sticking – here is some friendly advice and positive thoughts for you…

Be very grateful that your boss, who was perhaps a little foolish in giving you such a free reign with the reform plans, is sticking by you. Not only that, his deputy, and many of your conservative colleagues are towing the party line too.

Be relieved that people aren’t baying for your blood. Even though the Royal College of Nurses unanimously passed a vote of no confidence in you, they have not asked for your resignation.

Accept that although your intentions are good – you have got the fundamentals of this reform wrong.

Be encouraged that there is a way to save face and do the right thing. Ensure that the forum to discuss the ‘tweaking’ includes stakeholders from all along the patient pathway.

Acknowledge that hospital doctors and nurses, in the main, do a fantastic job and should have some significant say in the commissioning process.

Protect innovation – this is a major concern. How can GP’s decide what new techniques in surgery should be allowed?

Take heart from the fact that there is so much commitment from the 1 million plus employees of the NHS who really want you to get it right.

Take advantage of the expertise available to you. Please use my blog dated 22 March where I listed most the organisations who have voiced their reservations. I’m sure they all have some very helpful suggestions for you.

Remember..

‘Once we realise that imperfect understanding is the human condition, there is no shame in being wrong, only in failing to correct our mistakes’ (George Soros)

If you listen, learn, consult, amend and adapt, you will not only have saved your political reputation, you will have started to save the NHS too.

Have a great weekend.

Sorry seems NOT to be the hardest word

Even though delegates at the Royal College of Nursing conference today passed their vote of no confidence in Andrew Lansley, the UK Health Secretary, I had decided not to post a blog on the subject. I seem to be constantly harping on about the poor man and felt that maybe I should give him – and my readers – a break.

But then I saw the headlines on the BBC new website ‘Lansley sorry as nurses pass no confidence vote’ Sorry? Sorry! Had Mr Lansley finally admitted that his reform plans could significantly damage patient care and put an unnecessary burden onto GP’s?  I could imagine strains of the Hallelujah chorus ringing in my head……

But no – a quick scan of the report confirmed that my temporary elation was unfounded. Lansley is ‘sorry if what I’m setting out to do hasn’t communicated itself’.  ‘Communicated itself’ - the detachment of responsibility is staggering.

Lansley went on ‘I’m here to listen not lecture’.

In hope – I clicked on the video link to Lansley’s discussion with a select few nurses. He said he wasn’t there to lecture – but what did he do? Launch into the same old speech – hackneyed phrase after hackneyed phrase. Still no substance – no explanation on how this could work.

As I wrote last week – the Healthbill’s architect has now become a bigger issue than the Bill itself. This is more than a bad piece of legislation – it has been promoted by constant rehashing of weak arguments, poorly researched hypotheses and arrogant intransigence.

How many more health professionals will have to take previously unprecedented steps to bring about a rethink of the government strategy? The nurses didn’t vote for extra pay or better conditions – they voted against an individual who is in a position of great power and influence regarding patient care.

Someone asked me the other day why I ‘have it in for Lansley’. As stated previously – I was not a political animal before I started investigating the Health and Social Care Bill and it’s implications and I have no reason to ‘have it in’ for Andrew Lansley personally.

But I must confess that if I had the genes of the incredible hulk (some may argue that I do) – I would have now turned a very bright shade of green and suffered a significant wardrobe malfunction. Anger management may be the next step.

Enough. We don’t need an empty apology. We don’t need the government to listen. We need them to HEAR. And to act.

What a strange country we live in.

The Prime Minister has been urging the country to plan street parties to celebrate the forthcoming wedding. To facilitate this much needed jollity, he is asking local councils to relax the health and safety regulations, waive the need for insurance and review the safety requirements for road closures.

David Cameron feels it would be good for us all to have some fun adding "It's a chance for all of us to come together and celebrate the great things about our country."

There are many great things about the UK and I am very happy to be living here. But there is also some very odd stuff going on.

It’s a country where….

On 6^th April the government launches a ‘two month listening exercise to ease concerns over the NHS Reforms’ but at the Royal College of Nursing conference just a few days later, Lansley will only concede to speak to 60 nurses, 5 selected from each region who must agree to be ‘respectful’

A country where..

‘More joined up care’ is promised, yet district nurses in a home counties area, who each used to work with one GP practice, are now in a ‘pool of nurses’ serving a large area. Patients needing regular care in their homes no longer see the same nurse each time and the only way to ensure continuity for treatment of, for example, leg ulcers is for the nurse to take a Polaroid photo of the wound to leave with the patient for the nurse visiting the next day to assess progress.

A country where..

Despite Lansley’s insistence that GP’s are embracing the reforms, according to the Health Service Journal’s excellent consortia development map, there are still 16 Primary care Trusts without a consortia.

A country where…

We scrap Harrier Jump Jets aircraft and put the magnificent Ark Royal aircraft carrier up for sale and then join new conflicts.

A country where…

We profess to be an animal loving nation yet spend millions of pounds betting on a brutal race where two horses died. We applaud the winning jockey then give him a five day ban for excessive use of the whip - in other words, animal cruelty. (I must confess to betting on the Grand National this year – the first time for many years. But when I watched it I deeply regretted my involvement and will never do so again)

Yes indeed – this is a strange country sometimes.

But I will follow David Cameron’s lead and celebrate the Royal Wedding with a small party at home, where health and safety regulations don’t apply. Although, judging by previous form of my friends and family - and me -  after a few glasses of bubbly, maybe they should.....

How do you solve a problem like Andrew Lansley?

A leader has a problem when the person they appoint to solve an issue becomes the issue themselves. And hereby lies David Cameron’s dilemma

Cut to a vision of the Prime Minister and Deputy PM in their nun’s habits, in the abbey, singing to the tune from The Sound of Music…

How do you solve a problem like Andrew Lansley

How do you catch a cloud and pin it down?

How to you find a word that stands for Lansley?

A will o the wisp?

A flibbertijibbet?

A clown?

Many a thing you know you’d like to tell him

Many a thing he ought to understand

But how do you make him stay?

And listen to all you say?

How do you keep a wave upon the sand?

Oh, how do you solve a problem like Andrew Lansley?

How do you hold a moonbeam in your hand…..

Meanwhile, Lansley is skipping over the metaphorical mountains, perhaps not so happily now, catching the moonbeams of GP commissioning, patient choice and private sector cherry picking.

Theodore Roosevelt said ‘The best executive is one who has sense to pick good people to do what he wants done, and self restraint enough to keep from meddling with them while they do it’

Cameron has demonstrated the right leadership qualities by trusting his Secretary of State for Health to do a good job. But he made a fundamental error by not sense checking the proposals for NHS reform. And now every debate starts with the criticism that Andrew Lansley doesn’t listen, before addressing the issues themselves.

The ‘pause, listen, reflect and improve’ exercise is going to be time consuming and politically very costly for Cameron as he commits to rethink some of the reforms. So what should he do?

Sir Alex Ferguson, Manager of Manchester United football team is arguably one of the great leaders of a generation.  Love him or hate him, he has achieved consistently excellent results in a highly competitive marketplace while building team after team, mainly committed to the greater good. He justified his controversial decision to sell David Beckham at the peak of the iconic star’s abilities by arguing that no one player was greater than the club. So he had to go.

No one can question Lansley’s good intentions, but very few who really understand the health system can support his radical reforms. He still hasn’t been able to explain how his restructure will actually improve patient care and save costs.

Back to Roosevelt’s quote – maybe Cameron did pick ‘a good person’ for his health Secretary, but Lansley hasn’t done a good job with the NHS restruture. And now his profile, for all the wrong reasons is bigger than the Health and Social Care Bill itself.

Lansley has already been sidelined by the NHS reform roadshow launched by his superiors this week. But how far will Cameron go to repair the tatters of this political hot potato?

I would normally say I’m not a betting person, but have just placed my first online bet for The Grand National. I don’t fancy the odds of Lansley still being in post this time next year.

How many cooks does it take to spoil the broth?

Oh dear. The Coalition NHS Roadshow is already beginning to feel more like car crash TV than the ‘hearts and minds’ campaign launched by David Cameron, Nick Clegg and Andrew Lansley today.

Standing in identical white shirts - jackets removed to facilitate using antiseptic gel on their forearms as they visited a ward at a Foundation Trust Hospital – sadly they looked more like three uncomfortable pasty faced civil servants than swashbuckling musketeers ready to revive the Health and Social Care Bill.

If it wasn’t so worrying it would actually be quite funny. The PM and deputy PM put me in mind of parents trying to calm disgruntled neighbours after their wayward teenager aka Lansley, UK secretary of state for health had committed some random act of vandalism.

They have all promised to ‘pause, listen, reflect and improve’ and relaunched this campaign, not by listening, but by yet again delivering soundbite after soundbite.

Cameron started by stating his passionate and ‘personal’ belief in the NHS. I’m sorry Mr Cameron, but everyone in the UK has a personal tale to tell, good or bad about the NHS. Clegg then went on to say ‘This Coalition government will never mess around with the basic principles behind the health service’  Umm – you just did – with this Bill.

And Lansley – true to form, reverted to his original script, presumably feeling a little chastened that due to his failing to sell the policies effectively the big guns had to take over.

How many times must doctors, care organisations, think tanks, healthcare managers and commentators tell the Coalition: Its not about fluff – it’s about substance. These reforms cannot be sold effectively because they haven’t been thought through properly.

I applaud the trio for visiting a hospital, the health sector due to be most seriously disenfranchised by the reforms. But why will this ‘listening exercise’ be any different from the hasty consultation process undertaken before the Bill was published?

I would prefer not to see these three amigos (what a hysterical film – with Steve Martin, Chevvy Chase and Martin Short) trotting around on this particular bandwagon during the ‘pause’. I would like to see them behind closed doors, talking and listening to key stakeholders including hospital doctors, nurses and therapists. Formulating plans, fine tuning the nitty gritty of how improvements will work and outcomes be measured. Then they can come out of their bunkers, face the public and deliver action plans, realistic timescales and safety measures.

And then maybe Cameron and Clegg will stop looking so uncomfortable every time the NHS is mentioned.

Pause for thought and not much else

The UK press yesterday was full of reports that David Cameron and Nick Clegg would take over the ‘selling’ of the NHS reforms as they were unhappy with Andrew Lansley’s handling of the biggest shake up in the NHS since it’s inception.

Today we have been treated to a ministerial statement from Lansley, the UK secretary of state for health, saying that the government ‘is listening to concerns ‘ and will undertake a ‘listening exercise’  during a round the country tour.  He continued:

‘We want to continue to listen to, engage with and learn from experts, patients and frontline staff within the NHS and beyond and to respond accordingly. I can therefore tell the house that we propose to take the opportunity of a natural break in the passage of the bill to pause, to listen and to engage with all those who want the NHS to succeed and subsequently to bring forward amendments to improve the plans further in the normal way’

Is this a different form of listening to the type used during the consultation process? Nothing that the Bill’s detractors are saying now is any different from what they were saying before. In fact the only difference is that there are more of them and their tone is more desperate.

There is a brilliant cartoon in the UK Times newspaper today, showing a battered and bruised Cameron lookalike observed by two colleagues saying ‘he tried to back pedal and do a U turn at the same time’

But I don’t think that a U turn is planned and the back pedalling is more of a hiatus than movement in a backwards direction. In my opinion, David Cameron has always looked uncomfortable when trying to promote the Health and Social Care Bill. Back in January he delivered one of his biggest gaffs of his premiership by referring to the NHS as ‘second rate’.

It is now becoming patently obvious that there is no real substance in terms of how these reforms will actually work. Even the general public are beginning to wonder how a GP can do everything that the Bill promises AND find time to consult with their patients. Lansley as good as admitted in the House of Commons today that many of the experts, formerly employed by the Primary Care Trusts who have received generous redundancy payments can and will be re-employed by GP consortia within the next 6 months to fill skill gaps.

What does this new ‘listening exercise’ really mean? The debate in parliament is continuing as I write this piece, but I have had to walk away before my ‘listening’ abilities were severely challenged through boredom and death by cliché.  Being ‘passionate about the NHS’ is no qualification for dismembering it, limb by limb. If I hear ‘nothing about me without me’ again I fear I may not be responsible for my actions.

A few months ago I wrote that one of the most damaging effects of the uncertainty surrounding the reforms and the future of jobs was the ‘rabbit in headlights’ method of management, where very little was being achieved in the PCTs as people questioned the way forward.

It would now appear that this condition is contagious as the coalition stand still and stare….. or should I say ‘listen’.

The politics of healthcare

There was an interesting article in the UK Times newspaper yesterday entitled ‘Cameron puts brake on NHS reforms – Fear of political damage prompts second thoughts’

The piece suggests that David Cameron is rethinking the speed of the recommended changes and may try to take the political sting out of the restructure by slowing down the whole process of reform.

When I first started writing this blog last October, I assumed the Health and Social Care Bill was a done deal. I was, like many healthcare commentators, shocked at it’s proposed content and the sweeping nature and speed of implementation. Drastic change is costly, high speed drastic change is even more expensive. But Andrew Lansley’s intransigence and blinkered belief that his way is the right way, and the seemingly hands-off approach of his leader suggested that the reforms would go ahead, despite strong opposition.

Even when many organisations voiced their unequivocal concerns about the nature and pace of the reforms (see my posting 22^nd March – The List), Cameron seemed unmoved. Maybe the quiet determination of the marching masses last Saturday started to make an impact.  Many are beginning to sense that Cameron is realising the long term damage this Bill could do to the Conservative Party. Of course the public sector will argue against cuts, but why would so many general practitioners, the recipients of the £80 billion golden egg disagree with the goose? Even at grass roots level, those of us who previously had no political axe to grind are becoming polarised about these reforms.

At best Cameron has been naive in entrusting such a financial and emotional hot potato to Andrew Lansley, a man who simply won’t listen. At worst, this could be one of the biggest political mistakes Cameron makes in his career. According to the Times, ‘No.10 is seeking advice outside the department of health’. Pity they didn’t do that sooner.

Cameron must now proceed with caution. The horse has started to gallop away and it may be too late to shut the stable door. GP pathfinder consortia have been formed, chief executives appointed. Redundancy payments have been made, decommissioning of some services completed. A U turn is unlikely to be in the best interests of all concerned so will this Bill be reworked or simply tweaked?

Time really is of the essence as the Bill will reach the House of Lords in May, incorporating any new amendments. The Lybian Crisis must be taking up much of the PM’s time and energy, but he, and his closest advisers need to consider their next steps very carefully and Lansley and his team need to fine tune their listening skills – quickly.