Tag Archives: National Health Service

NHS Five Year Forward View: still no skin in the game

NHS England and other English health organisations have produced a five year ‘forward view’ [here]. The refreshingly short and precise document establishes a new approach to the

English: British National Insurance stamp.

“Skin in the Game” British National Insurance stamp. (Photo credit: Wikipedia)

English health service, something political reform has failed to achieve since perhaps the beginning in 1948, namely the realisation that top-down reform really doesn’t work. This is a bit surprising given how oftenNHS folk have travelled, particularly to the US, and other places, where the notion of a top-down approach is anathema. All these visits, reports and breathless commentary on lessons learned has really, it now seems, to have been for nought.

We also now have some explanation why the attempts to adapt lessons and approaches from other countries has failed — the heavy overarching deadweight of central control has stifled innovation. Given the additional volumes of studies of the NHS, think tank policy papers, round-table discussions and consultation, researchers, in the UK at least, seem to have been trapped within their own paradigm and failed to see the internal fault lines that pointed to this blind-spot.

Anyway, that said, we now see that Simon Stevens, head of NHS England, has not wasted his time in the US, as not only does the report quote Lincoln’s Gettysburg Address, but tacitly acknowledges that the US (and other countries, but not in the UK) favour decentralised experimentalisation with payer and service delivery flexibility.

Lawton Burns in his important book on healthcare innovation [The Business of Healthcare Innovation, 2005, @Amazon] notes that one reason the US dominates the health technology innovation space is precisely because of the flexibility to experiment, try new things in healthcare service development.

This report, together with the other surprising ‘discovery’ that the funding of healthcare and social care are also part of the problem, after decades of dysfunction, shows that there is now a window within which major changes can be achieved to remove perverse policy incentives, drop barriers to change and get rid of the zombie administriative rules that kill off good ideas.

So where might this all go? Yes there are some very good examples already in place and one hopes more to come. But putting the cat amongst the pigeons may have other rather interesting consequences.

If we see increased power shifting to cities, will we see Swedish-style county-council run healthcare? Such an approach has the merits of democratic accountability, and challengingly, puts funding options within local taxation strategies. Given years ago I advocated with the other big city in the UK a local-council run NHS which caused no end of criticism, I would be surprised if this doesn’t come back on the agenda.

The rising priority of prevention also highlights one weakness of the NHS.  Dating back to 1819, employers had legal duties imposed on them for the health and safety of their workers, a responsibility which the creation of the NHS in effect removed at least in respect of health.  The report notes that employers pay National Insurance as though that were sufficient motivation. What the report fails to add is that NI employer contributions are not experience-rated in terms of the health of the workers themselves. The NHS has flirted with workplace healthcare in the past, but the concept of “primary care in the workplace” has failed. Stevens will know (and others should) how many countries separate workplace health from general health. Some places call it “workers compensation” and it involves risk-based employer premiums, adjusted for actual workplace health, injuries and accidents. Countries with such systems include the USA, Canada, Australia, Japan, and others.  What taxation does is risk-pool, but that means it is hard to link individual behaviour to risk.

American Accountable Care Organisations and other similar approaches in other countries of long-standing, only work when organisations are free to associate in ways that make financial and healthcare sense. US ACOs are forming partly in response to the financial signals in healthcare legislation there, but these signals, coupled with systems of rigourous inspection (and a failure regime), focuses minds. Vertical or horizontal integration in the NHS is needed, and would serve to remove at a stroke the barriers that bedevil patients. I’ve seen how building primary care onto the ‘front’ of the hospital enabled speedy patient access to specialists (they simply came down from the wards) and avoided inappropriate admissions. Buying a nursing home added a step-down into the coummenity releasing pressure on in-patient beds. GP integration toward secondary care pulls diagnostic imaging and laboratory technologies toward the patient, and removes hospital monopoly control of what is the major cause of delayed diagnosis.

But, the end result is in the UK, consumers, patients, employers, have no real skin in the game, which in these days of behavioural economics means that it is additionally challenging in the NHS to activate the essential incentives to align patients around their care, or employers around healthy workplaces other than through moral suasion.

We may need to revisit how to use the NI contributions as co-payments to create the necessary financial incentives that serve to quantify risk to both patients and employers.

Of course, one should be grateful for small miracles, which is why this report is welcomed.

P.S. I suspect this can be done without new money.





Cancer Services in the NHS are coming apart at the seams: time for a new paradigm

Measuring Up: the health of NHS Cancer Services is a report from Cancer Research UK.

I have no difficulty accepting much of what they have discovered and the report’s key points are sensible. But, two main conclusions are unsurprising and disappointing: more money and better leadership.

There will never be enough money, so we need to think differently about how we organise care itself. More leadership is a typical lament which says that the people responsible for the service haven’t done what they need to do. When I read reports such as this that call for more leadership I can only shake my head that they were not able to think further about the underlying causal landscape.

Their use of tipping point language is useful, though, as it does suggest catastrophic, rather than incremental, changes are likely. A tipping point means a move from one state to another (like tipping over the milk pitcher), where other factors come into play (otherwise it wouldn’t be tipping!). That suggests that there will be a change of state in which the old rules are unlikely to apply or be useful. After Kuhn, we call this a paradigm shift. Edward de Bono characterises two situations: one he called a problem, where you use existing rules; the other is a crisis for which you need new rules. My take is that the NHS is moving into territory where the need for different thinking is more important than problem-solving. That healthcare is a complex (wicked) and adaptive system should alert us and not surprise us that solutions create new problems and indeed crises.

Based on the report, though, we’re more likely to see hyperactive civil servants and NHS “leaders” rushing about with Powerpoint presentations full of exhortations and flow charts, accountability matrices and maps. We’ve tried that so often, one wonders if there are any other tools in the box. However, that the current state of affairs may have been caused by past reform and changes is an important insight, but to argue for essentially what is more of the same is plain silly. If past actions have destabilised cancer services and tipping is likely, then new thinking and new rules are needed. Did I miss something in the report?

If we take the simple flow of patients through the system, we are told the rate of entry is rising as GPs shift to ‘urgent’ referral, presumably the only way they know to get an oncologist’s attention, but the velocity through the system hasn’t changed. Why should that be surprising when resources are rigid and constrained by NHS structures (such as lack of effective transfer of patient information), and what appears to be performance measurement of the wrong things, creating perverse incentives.

The diagnostic phase is what appears to be rate-limiting across the patient and treatment pathway and hence is the primary blockage. While increased investment in diagnostics would be timely, how to do that is where a paradigm shift is needed. The delay in procuring proton beam equipment (so much in the news) illustrates the procurement logic that undermines service delivery. Entrepreneurial creation of free-standing diagnostic centres, providing on-demand services to oncologists and patients would be one way to deal with this. Does the NHS need to own the equipment, labs etc. or does it just need access to the service? By-passing the GP would also be another option, as the gatekeeping function appears to be another form of avoidable delay (ask women how long it took for ovarian cancer, for instance). Would it not be better for patients to access directly oncology diagnostic centres, which might also speed GP referral in turn?

The policy-down focus on leadership has clearly produced organisations of dubious purpose, but with evocative titles: Clinical Senate. Wow! But systems are judged by their performance, not what they’re called. A focus on leadership shifts cognitive priorities from a service orientation to one of lining up organisational structures, job descriptions, role definitions and mandates, meetings, minutes, but distractions if the challenge is where the rubber meets the road. The intersection of patient with system defines the leadership challenge, not the other way round.

So, what is to be done? I don’t buy the authors’ argument that change-weary people don’t need more change. They may embrace the logic of wholesale paradigm change if it got rid of the nonsense that stops them from doing what needs to be done. My take is that there is a strong case to be made for unbundling cancer services (this logic can apply in other clinical service areas, too) defined by the demands of the patient pathway. I would also look for ways to encourage entrepreneurial solutions, particularly in the form of investment in diagnostic technologies, and in enabling oncologists to work autonomously with each other and with patients. This would call time on the hospitals’ monopoly control of oncologists, cancer diagnosis, testing, and services, which is organisationally rate-limiting, and many of the identified problems are consequences of a system subjected to serious rate-limiting blockers, but lacking the ability to alter its structure to bypass, elminate, or reform those blockers.

In the end, the report is a narrative exhortation to get people to meet and plan to do what they are currently not able to do, or otherwise they would have done what needed to be done. Why not?



Health Data: the problem of distinguishing between public and private sectors

The Wanderer above a sea of fog by Caspar Davi...

Why limit your view when you can see this far? The Wanderer above a sea of fog by Caspar David Friedrich, around 1818 (Photo credit: Wikipedia)

“The Open Data Era in Health and Social Care”, prepared by GovLab (NYU) has been released.

I have no issue with open data, and the more open the better. However, doctrine may interfere in respect of the way data are viewed in the UK.

The typical model is to focus on the NHS, as the main provider of healthcare services. Certainly, this makes good sense, on its own. But the NHS is not on its own. The title is a bit misleading, in that while Social Care in included, the English NHS this is not integrated, suffers from bureaucratic accounting rules that prohibit pooling of budgets (hence the problems with the Better Care Fund), coupled with means testing, a cash market, and a major role of charities in filling in service gaps. Countries with patient-copayments and transaction data manage to integrate health and social care around the patient because of the ability to avoid arbitary distinctions between provider types and their ownership. As a result of what is both a strength and weakness of the NHS, policymakers have had and continue to have considerable conceptual difficulty integrating public and private provision into a patient-centric and whole-system model of seamless care.

Healthcare is bigger than the NHS as people in the UK can buy private health/medical insurance, pay cash for private treatment or use private hospitals under NHS contracts. In addition, patients seek services from dentists, physiotherapists and pharmacists, and others, who in the main are outside the NHS in terms of practice patterns.

Let’s take medicines. Years ago the NHS explored electronic prescribing, a project initiative I was doing some policy work on. I had asked whether private prescriptions and dental prescriptions were to be included and was told, no, they were excluded as this was an NHS project. Of course, thinking such as this means that they were failing to look at the whole system of medicines prescribing. A patient for instance who is prescribed an antibiotic by a dentist (and they prescribe a lot of antibiotics) would discover not only that that information was not available to their GP, but the GP would likely not know that dental surgery had even taken place. And private/independent prescriptions were simply off the table!

The only way that Open Data Era thinking can prevail is when the English NHS and the Department of Health adopt whole systems thinking. The modern world is full of boundaries that are being breached by new technologies, that are challenging assumptions of the past that in the future will prove dysfunctional.

The NYU report (I am surprised at the lack of whole-system perspective — perhaps they didn’t know about the wider health system??) does not address the distinction between NHS and private/independent data (though they do make the point that Open Data might be used along with private or independently held data, but in the context of my remarks, this seems a fudge).

I won’t go into a detailed analysis of their logic model on page 45 of the report which crystalises their essential argument. Logic models are conceptual models that link various elements (inputs, outputs, outcomes) to desired impact in a coherent (logical) way. Needless to say, they start with NHS data. Examining the Activities/Outputs parts, would suggest that the full realisation of the stated benefits will not be possible. Limiting the data in, as the model does, means that achieving operational efficiency or resource allocation (impacts) will lack private sector comparators for instance. One output, Policies Created/Changed, is immediately compromised by the inability of the model to account for the role of the independent/private and not-for-profit sectors, which is about 10% of the total activity and expenditure. Indeed, their definition of ‘internal users’  (page 48) excludes non-NHS entitities, and they aren’t seen as ‘external users’ who might need to access NHS data. Furthermore, the approaches proposed to capture measurement limits the focus to state-mandated bodies (i.e. NHS), and therefore limits the ability of measurement to assess potentially new approaches to care that may be invented. So much for measuring innovation.

It would have been better to start  with the needs of data users and their objectives, in a whole system approach. This is the fundamental weakness in the logic model and limits the report considerabley. In the end, it makes me worry that the initiative will in the longer run fail to be as successful as it might be.As Einstein said: “No problem can be solved by the same kind of thinking that created it.”

Is Simon Stevens the new NHS Wizard?

It is no doubt reassuring for many in the English NHS that Simon Stevens, the new CEO of NHS England, comes with new ideas — they don’t have to think so hard. I guess people have forgotten their criticisms when he left the UK to work for a commercial provider: UnitedHealth, in the US.

What apparently has happened while he was in this rather different environment is that he has returned to the UK with a box load of fresh thinking.

However, he must be wondering why all those people concerned with improving healthcare services had not thought of them already. Why he has to do this is really worrisome as it is just further evidence that the NHS is a permission-seeking culture that takes ages to innovate even the most mundane improvements. I have no difficulty with what Stevens is saying, and I hope he legitimates even more radical initiatives, if all it takes is for him, like in Star Trek, to wave his arms and say “engage!” for people to get on the with jobs we all thought they went to work everyday to do!

We’ll hear a lot about the small hospitals idea now that it has been reignited as a ‘big idea’ (little idea?). People will now say that it is a good idea, timely, insightful. Or as one person on the news said today, that this is recalibrating what the NHS does. Hmmmm. Methinks the lack of insight into the problems that Stevens highlights with his comments is not reveletory, but just more evidence that the NHS eats its young. Perhaps we should listen less to the economists who are trying justify expenditure models in the Department of Health, and more to people with imaginative ideas to improve healthcare with the money they already have.

What Stevens seems to have learned from his time outside the UK and in the US (and I expect he’ll pepper his comments with examples from other countries, but the US is the innovation engine of note) is the need for healthcare providers and payers to be able to use their respective roles to improve care. So-called Obamacare mandates payer-side reform with a pluralistic perspective yet the English NHS has limited payer-side instruments to really drive reforms (despite CCGs). The ability to repurpose money is really important.  Providers for their part are struggling with health reform in the US but it is driving innovation. What is stopping NHS Foundation Trusts??

Some examples from the US:

1. Virginia Mason Medical Center worked with Intel to develop a totally new approach to organising care with a focus on creating “the perfect patient experience”. The underlying logic builds on Toyota’s Production System and was used to rethink clincial work and patient care processes. (see Kenney’s Transforming Health Care, CRC Press. Forward by Don Berwick by the way.)

2. The Mayo clinic has been working on the focused factory/solution factory model to rethink the alignment of patient case complexity and clinical organisation. Given work I’d been involved in the late 1990s was the first structured patient segmentation model ever used in the UK, moving toward a segmentation model is hardly rocket science anymore. (check out the May 2014 issue of Health Affairs, article on cardiovascular surgery by David Cook and colleagues at Mayo).

3. Michael Porter, of Harvard competitive strategy fame, is applying his considerable analytical models to healthcare. He wrote a great book, Redefining Healthcare, about the US, and did a powerful critique using similar models on the German healthcare system. I just wonder why he hasn’t done the UK….

4. Patient activation is on the agenda in the UK, following a recent paper from the King’s Fund. But why did it take a decade for them to discover something that is old-hat as an operational strategy to patient adherence. The problem in the NHS is that there is insufficient priority to spending money to anticipate care needs. I had a project to assess a project on how weather impacts acute exacerbations of COPD; all it took was a telephone call to tell people with COPD risk to stay home on days when the weather was for them risky. This sort of good thinking wasn’t continued, despite evidence that it worked. Oh well.

5. Berwick’s work, first published in Health Affairs, on the “Triple Aim”, is coming up to 8 years old, and it seems Wales and Scotland are using it, and Darzi and colleagues did write about it in a recent issue of Health Affairs, but it wasn’t published in the UK (perhaps the UK is poorly served by academic researchers or are publishing in obscure journals with paywalls to ensure dissemination is limited to subscribers). Triple Aim is a powerful analytical model to probe wasteful, dangerous and unsatisfactory care. I’ve been using the Triple Aim in my own work constructing decision architectures of patient treatment pathways, but the ability to convert the results of the analysis into action remains the sticking point. Payers haven’t been commissioning the work, and they are really the problem owners as much providers.

6. The Evercare programme, which Steven’s ex-employer runs, has been around in the US for over 30 years and involves, in part, specialists visiting at risk people at home and works well. The NHS tried to translate it to UK practice, but the key benefit, of home-visiting specialists, was implemented. The results was sub-optimal and probably a complete waste of time and money. Gravelle and colleagues produced an evalution in 2007, published in the BMJ.

Don’t misunderstand, many people working in the NHS want to make things better. The problem I have is why good ideas need to be permitted. I guess it is all about the politics of healthcare, but I thought the new model NHS was supposed to bury the supertanker logic and create bureaucratic distance to allow that.

The NHS solution to challenges is to bureaucratise them (create entities and bodies with mandates) and issue guidance, which perpetuates the permission-seeking culture.

Having experienced healthcare in other parts of Europe, there are many important alternative approaches which do not require new bureaucratic organisations. A looser more flexible approach to pursuing innovation may be the trick. Oh sorry, the NHS tried that with the Innovation Institute for something or other full of people running around the country with powerpoint presentations.

Just think of Sweden — healthcare run by the local council, and with co-payments!

Driving Integrated Care


A model of integration — ants do it

Two items in the publication, Public Finance (pledge to integrate care and integrated care a long way off), illustrate the frustrating nature of health system reform in the NHS.

Is integrated care hard to do? Are there perverse incentives in the system (things like free-riders and moral hazard, even NIMBY) that work agains effective change in healthcare, and in particular the neverending saga of the NHS? I suggest the problem lies in the methods chosen to solve the problem of integrated care, rather than the value of the goal itself.

  1. Over the years, the NHS has made great strides improving the quality of managers (I used to teach them and co-direct an MBA full of NHS managers) but many appear to be unwilling to speak ‘truth to power’ and take full responsibility for dealing with, in this case, integrated care. Instead, we continue to seek both permission-seeking behaviours in the executive suites of the providers and purchasers (just hate the commissioner language, so gutless), and reluctance to challenge the status quo, perferring the herd mentality.
  2. Foundation trust status has done wonders for improving institutional governance, but operational performance (as we know from Francis) is still uneven. I believe this is in part due to NHS organisations being incredibly weak in terms of their analytical capacity (working with data, modelling etc.) to understand and respond to day to day challenges, which undermines the ability to plan and structure strategic direction in response to changing health dynamics.

Integrated care is not hard to do but does require understanding the patient journey through the system and how best to organise the bits. So where does the NHS go wrong is solving this particular problem?

The models used, and the two articles evidence this are broken. What models does the NHS use? It uses approaches which I liken to ‘team hugs’ and ‘pass the teddy’, feel-good leadership approaches, which do not focus on the outcomes to be achieved, but processes, which may or may not lead to a solution. The result is an overuse of:

  1. “joined up care” rhetoric continues to confuse, yet we still don’t know what it means though it sounds like something we would want; I think it is what we thought we were paying for all along!
  2. “commitments” by those involved become contractual type language of agreement, and which are used to “clarify” what can and cannot be done. But again we see no focus on the problem, but on regulatory and other controls, which if they need clarifying, are perhaps useless if not actual barriers, so why do they exist in the first place? When do we bell this cat?
  3. “ambitous plans”, which is code for more paper which no one will read but which will clutter people’s diaries with meetings about meetings about meetings….
  4. “examples” of what can be done is supposed to demonstrate to people that what they want to do can be done; but if these folk are truly in charge of their organisations and have taken ownership of the problem, would already be probing the possibilities
  5. “pioneer status” is code for people who get to the early money first and get to take one of the examples and try it out by developing a plan which people can talk about, and around we go again.
  6. “top-down” is to be avoided, but is said as a reminder that ‘you are in charge’ just in case you were confused, but given the wider context, you actually aren’t in charge as if you were, we wouldn’t be having this conversation.

The reliance of policy-based tools, though, drives a logic that may not be as flexible as possible to achieve integrated care. If it is such a good idea, what is stopping people?

Integrated care can be driven on the purchasing side by, for instance:

  1. Incentivising providers through bundled payments for whole packages of care that cross institutional boundaries;
  2. Incentivising the emergence of new types of providers to achieve care integration;
  3. Tracking outcomes for processes of care.

Integrated care can be driven on the provider side by, for instance:

  1. Pursuing forms of vertical or horizontal integration that achieves a measure of care integration for specific populations of patients, by avoiding the problems of inter-institutional referrals;
  2. Creating new units of care activity that overcome internal organistional barriers, such as bolting on primary care onto the front-end of the hospital, using step-down units and other alternative provision for different strate of risk;
  3. Ensuring the urgent does not wag the dog and draw resources away from better service stuctures — why does is emergency service so overwhelmed yet the capacity of the system to anticipate and predict so weak?
  4. Bridging skill mix cartels and protected working practices embedded in professional regulation to enable flexible working.
  5. Did I mention working 7 days a week and running at least 18 hours a day? An example of the failure of integrated care is a hospital not discharging a patient on a Friday because [1] the lab doesn’t work late or [2] social services won’t start home care on a Friday afternoon. Integration means doing things when they need doing, not when it is convenient to do them.

It all comes down, in the end, to how you solve a problem. The NHS continues to use methods that have failed in the past, yet these tools continue to be trotted out over and over again.

There are better ways. Email if you want to know more.


Systems Goverance is Confused in the NHS White Paper

The English NHS is in for further reform as the flurry of consultation documents and the White Paper evidence. Overall, NHS reforms have been generally weak in having a thought-through systems governance approach. I think in part this arises from perceived problems with two areas: the role of the private sector: the systems governance of previous reforms has tried to ignore this sector, and in effect partition the health market certainly in England, with the result that a single playing field for providers couldn’t emerge. This was compounded by the previous government’s views that NHS providers could fail twice before being of public concern (a silly and ideologically driven position). The second problem has always been the purchasing side (a.k.a. commissioning), where there has been over the years feare of ‘letting the market rip’ (as if we somehow markets are generally regulated anyway), anxiety about purchaser impact on provider viability (again an ideological position on the how to deal with failing public institutions — the usual response it to prop them up with more money). or more generally a plethora of initiatives (such as World Class Commissioning — I wonder when this one gets buried?), whieh exuded more style than substance.

And so it continues with a failure, I think, once again to get the commissioning side of the health system balance sheet cleaned up.  One of the key things that needs to be central to systems governance is clarity of mission of the various bits that make it go, and how conflict is managed, mainly for systems-level problems that need to be resolved within the system, rather than constantly being taken back into the political machinery for resolution. Given that the coalition government wants to create some distance between the Department of Health and the regulatory oversight structures themselves (Monitor, CQC, NHS Commissioning Board seem the main statutory bodies here plus the GP Consortia and providers as agents), the possibility of conflict emerging between the Board and the other two regulators is real.

The NHS Commissioning Board will have oversight of GP Consortia, and in effect givea them a licence of fitness to practice; though this isn’t the exact terminology used, the Board does decide if GP Consortia are handling financial risk well, within the overall clinical frameworks and other guidance. And what of failing GP Consortia?

I am troubled in particular that the Board will be commissioning services for primary care and for national and specialist services. This is where the core problem for system governance lies, as the Board has a potential serious governance conflict between its oversight and regulatory role and its activities as a purchaser (sorry, commissioner…).

Who oversees the NHS Commissioning Board’s commissioning and why should anyone trust them to do a good job in absence of suitable oversight — are they not both poacher and gamekeeper? Since the Board will be commissioning, and also overseeing commissioning by GP Consortia who must commission within the any willing provider framework, will the Board be similarly constrained? While GP Consortia’s behaviour is subject to oversight by the Board in respect of commissioning decisions, the Board appears not to have any oversight in this respect (apart from the usual warm words that folks will consult and work in partnership, etc.) My worry is that the collective effect of GP Consortia commissioning may have some relationship with the desirability or not of specific national or specialist service commissioning. I am also worried about the logic underpinning what national and specialist in fact are, as this type of thinking is really ‘old school’, and is a remnant of centrist thinking. The epidemiology and service logic at work here could also find itself at odds with the possibility of unbundling and decentralising or otherwise restructuring such services (where capabilities, technologies, and opportunities present themselves), a possibility that innovation might unleash, but which cannot be anticipated by this particular solution. As well, we are too aware of the failure of prestigious providers to fail in their quality (do we need to mention neonatal heart surgery?)  So the assumptions underpinning the centrist logic of national and specialist commissioning should fall both within the remit of CQC and Monitor and under the wing of GP Consortia.

The proposed NHS System Governance System, 2014

Apart from all the other things that the Board will do (a very long list) adding into this mix managing commissioning relationships with providers seems not just a task too far but a source of considerable and likely conflict. This is to say absolutely nothing about how they will handle the commissioning of GP and other primary care services, which entails commissioning services from people that, in an different guise as GP Consortia, they in effect regulate.

How to do that? Well… Critical to effective commissioning is ensuring that adequate analytical capacity exists at the levels at which decisions are being made. If, and I see no reason to doubt this, GP Consortia do their jobs well with excellent analytical capacity to inform their decisions, they can, in some collective form, create an appropriate structure to handle the commissioning of national and specialist services. This will ensure the better integration of commissioning decisions, smooth the flow of patients and resources across the borders of GP Consortia, and clarify referral protocols. It will ensure that these national services are really national or specialist and are governed by common standards of regulatory oversight. Importantly, it avoids the potential for gaming the system, as it removes an incentive for providers to lobby for the creation of national or specialist services as a way of protecting their service infrastructure, and ensures that any complacency in service quality improvement is avoided by being able to for specialist providers to forum-shop for a regulator.


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.

De-layering the National Health Service in England

Bureaucracy - Magritte

Bureaucracy by Magritte

The well-known organisational practice of delaying has emerged as one way to achieve public sector austerity. This is to be aplauded, not regretted as it is applied to the English NHS. In fact, those looking to the total costs of running health systems should be taking serious note of what this is all about.

Public sector work has tended to favour layers of bureaucracy, to respond to the tendency of civil servants to do what is called rent-seeking, which in the end means building empires, or expand a sphere of influence. In the regulatory context, it is called regulatory creep, as mandates are progressively, but subtly expanded by rent-seeking regulators.

The end result is large spans of control for civil servants, but little actual progress in achieving public sector objectives and goals. This stifles creativity and further rigidifies individual behaviour into highly structured ways of working — further compounding the potential waste of public money.

In addition, the tendency of bureaucracies to create bureaucracies means that individual jobs are often highly compartmentalised from other jobs, as individuals carry specific dossiers or briefs. The compartmentalisation of government into ministerial portfolios adds additional barriers to sharing work, ideas, or insights across government, further compounding the opportunities to deliver better value for money.

The White Paper on the NHS plus the overall behaviour of the UK’s coalition government reflect a consistent and simple message about the way the public sector should be organised to undertake its tasks. De-layering means removing non-value-adding levels of organisational bureaucracy, layers with the sole purpose of either move information up (or down), or checking or verifying the work of others.

The NHS itself has been too long likened to a supertanker, but a school of fish is what we want — nimble organisations that can respond quickly to change. Instead, some commentators have questioned the proposed reforms, asking what will happen when you need to pull some strings centrally to get things done? What these commentators don’t realise is that healthcare is a complex adaptive system, which means that there aren’t really strings to pull.  Decades of belief in this assumption has produced ill-thought out control mechanisms, and inappropriate and pointless layers of supervisory control (such as Strategic Health Authorities), which really can be only weakly effective at best and destructive of initiative at worst. It is not unusual for SHA staff insert themselves into processes to assert  a measure of control reflecting their priorities, ignoring the real needs of people dealing with a front-line challenge.  Indeed, the rent-seeking behaviour of these quasi-civil servants challenges the validity, the very authority, of those who own the front-line problems in healthcare to actually solve these problems. Before all this, we had the failed Modernisation Agency, the failed NHS Training this, or NHS University that.

The insights in the White Paper have put paid to the assumption that overarching control mechanisms can work, putting the onsus on problem owners to solve these problems. There are proposals in the While Paper which accept the need for flexible and dynamic responsiveness to the local and real-world interface between the patient and their care provider. Many in the NHS will fail to understand this, and as in any organisational change process  there are some people who ‘don’t get it’.  By and large, failure to alter personal behaviours is a recognised barrier to implementing reforms, and many such people will need to be shown the door and encouraged to pursue other careers. The NHS often forgets to bury its dead and it frequently eats its young, meaning that failed bureaucrats get recycled and good ideas destroyed by a controlling culture.

I have immense confidence in the ability of the right people to solve the problems, (indeed of the ability of GPs to ‘get it’). There are also real challenges for the chief executives of the foundation trusts and other NHS providers to demonstrate the necessary leadership and management skills to drive out the costs and inefficiencies that are shot through the system; CEOs will be particularly challenged as they must now actually manage, and not simply administer a publicly funded entity and avoid rocking the boat.

There are too many quangos and other organisations around staffed with individuals from failed agencies so one must be vigilant to ensure that the delayering process does not just turn into a recycling exercise.

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Charles Perrow’s important work, Complex Organisations, highlighted the hierarchical structure of professional organisations and asks important questions about how and why we construct overly complex organisations, and why they can become dysfunctional.