That thundering herd


A herd of leaders charging an outcome

What is this loud thundering I hear across  England as people begin to adopt the new thinking on the English NHS from the coalition government?  Not a year ago many of those same people were saying quite different things. What has changed?

Golly, but now they are all trumpeting the appropriateness of outcome measurement in the NHS, something that should have been the case decades ago, but got hi-jacked by bureaucracy.  As I have said elsewhere, the patient is the most disruptive force in healthcare, and as the ‘auditor of one’ can drive quality and service integration in ways that top-down monster plans never could.

I’ve worked on developing outcome measures, and perhaps the one thing that is important to realise they are best developed as emergent measures from within the delivery of care as much as designed by a room full of experts and some evidence base.  My preference is to develop a system using something simple like a balanced scorecard, (with perhaps 4 to 6 critical measures under each of these four headings, so around 16-24 measures), something like this:

  1. Measures about how well the healthcare commissiong process interprets healthcare requirements, and how well a provider responds to manifest demand for its services. [Measures here focus on the ability to interpret the dynamic nature of the healthcare environment.]
  2. Measures about how efficient a healthcare provider is in organising care, including interconnectedness with other providers (handling referrals across institutional boundaries). Also measures of how effective commissioning processes are. [Measures here focus on efficiency, doing things well.]
  3. Measures about how effective a healthcare provider is in delivering outcomes, including with other providers (integration of capabilities linked to specific desired results). Also, measures of how effective commissioners are in what they do. [Measure here focus on effectiveness, doing the right thing, mindful that the right thing has always been about outcomes, not outputs.]
  4. Measures of how well the various health system actors such as commissioning bodies, consortia, providers, professionals, patient groups, etc. learn how to improve what they do, including driving forward change, introducing innovation, learning from mistakes, and developing solutions. [Measures here focus on ability to evolve, innovate, learn, change.]

None of these require central thinking and with properly strategically managed organisations would have been the norm, but for the various distractions over the years). They can be developed into an hierarchical performance model to tie together what individuals do, what processes are used, and how organisations institutionalise practices to achieve outcomes. (There is a cognitive model at work here by the way.)  This puts the measurement focus onto individual organisations, and not onto arbitrary aggregates (such as regions); the focus also requires much stronger strategic abilities within the leadership of system actors, and greater operational attentiveness by everyone. Hospitals, GP Consortia will need much improved analytical and operational research capacity within their institutions in order to more accurately interpret their local environment and respond in a timely manner; this important capacity has been held higher up in the NHS (in all its devolved parts) and indeed important operational research capacity and mathematical modelling seems the preserve of the Department of Health, whereas the problems are at the front-line. Shifting resources to where they are needed removes top-down performance management as the focus is now measuring performance in terms of delivery, not activity. Keep in mind, too, that as a complex adaptive system, there are no ‘strings to pull’, and that does change the nature of any information that is reported.

Change always requires that individuals learn to behave differently. Organisations are how we group together the behaviours of people to achieve certain goals. It is importnat to understand that:

  1. Some people have trouble altering their behaviour, especially if it requires initiative and originality which in the past was not rewarded — so they may need either help or perhaps counselled out, particularly if they are in leadership positions (and beware the recycling of failed leaders);
  2. Some goals may not require some organisational arrangements that are currently used, and may need to be changed (think of the potential disruptive potential of e-health); but people have a great deal of difficulty with ‘creative destruction’ of publicly funded institutions, which is why public service institutional renewal can be so difficult.

No one said all this would be easy, but it should be done better.

I just hope that great thundering herd is also thinking as it charges along.