Activities to help NHS leap forward

Shoal of fish There's a need for a step change in performance in the NHS. Will the current procedures work or will they need to be changed? These were two statements that started the latest Thought Leadership Debate on transforming health services.

Professor Eddie Obeng, learning director of Pentacle, opened the debate. 'The first thing that you have to ask yourself,' he said, 'is whether the approach is likely to work'. He then compared the performance of an average UK project to a family of two parents and four children going on holiday from London to New York. He said that in the equivalent project the Family ended up in Quito having spent 40% more than planned and leaving two children behind!

He said that planners and policy makers have had to update their thinking to match the current reality of the world. Since today the pace of the world is faster than our ability to learn and change, centrally imposed solutions are very likely to fail to achieve the results hoped for. However, unlike traditional thinking, in a complex fast changing world modularity works. The internet has no CEO and yet its modularity allows flexibility, innovation and speed. Much of the NHS is modular and planners should try to use this to their advantage.  

With the modern pace of change policies have a shorter shelf-life and are often out of date. Even worse, because of the change, information becomes swamped by data. In a slower world the questions to be answered are understood and so the right and appropriate data can be collected to answer them. To collect data without an understanding of the underlying questions you wish the data to answer simply means you’ll be swamped in data.

Finally, there is always an over-focus on the processes, systems and procedures. The real challenge in change is the people. People can actively help, resist or undermine. Any change which is attempted without engaging the stakeholders is in for a rough ride.

The next speaker was John Bennington from ANODOS Information Systems Strategy. He started his speech with some personal background.

He said that a couple of years ago he decided to take his company into the NHS in a moment that colleagues variously described as insight/madness/altruism. He felt it was insight as the NHS seemed ripe for transformation, especially as it exhibited what he saw as three key characteristics, which seem to be common to transforming sectors:

  • significant intervention/interference from government or a regulator;
  • serious supply/demand shortfall;
  • new technology opportunities.

He added that the outcome of multiple organisations transforming in a single sector seems to be a restructured sector. You can think of examples - insurance a decade or so ago, media now and others.

He then went on to clarify that the definition of business transformation is about achieving a step change improvement in performance, measured as:

  • 10s of percentage points reduction in cost base (of area targeted, usually the core of the business);
  • 100s of  percentage point reduction in transaction cycle times;
  • often 100s of percentage point reduction in error rates.

After this he moved on to some common themes that transformed organisations in different sectors seem to have found useful and gave some examples:

  • smarter use of assets - notably property;
  • digital - no paper or analogue media;
  • joined up service delivery - no silos - internal or external, seamless processes running across our network partnership;
  • just in time - workflow across partners;
  • proactive not reactive - as in property management.

He expanded on a couple of these and applied them to the health sector.
He asked, 'If we looked into our property assets, and we had the processes and systems to ensure we fully utilise our theatres, wards and other expensive spaces, would there be commercial gains as well as improved patient experience?'

And also 'We've digitised our film - if we digitised our paper, especially health records which are at the heart of our business process, would this reduce errors and improve staff and patient satisfaction? Delays to electronic patient records are no excuse, what's wrong with EDRMS and workflow?

One of his final points was, if it's all so obvious, why hasn't it been done? It's not trivial he said, we have to change people, competencies, processes, systems and infrastructure all at the same time on a large scale as well as manage the money, communications, procurements and more.

He then posed some questions for people to discuss over dinner about why is it that the NHS has inhibited transformational activity, and what might be the key enablers that are missing today?

In particular:

  • Could it be that the private sector made some early mistakes? How did these get turned around?
  • What did other industry sectors find they were missing?
  • What are the inhibitors for the NHS? Do these align with what other sectors found got in the way? Could it be there are cultural issues?
  • Are there other relevant themes from your experience that could apply to the NHS?

The final speaker was Sheila Bullas, director, iBECK and BCSHIF secretary.

Sheila opened by saying that transforming health services has become a buzz word applied to the smallest of changes. While all such improvements are to be celebrated, they did not add up to the step change in performance that is needed.

Information systems can be a great enabler of transformation, but she questioned the NHS track record of systems implementation and their use to support business change. She said that a lot of hospitals have the same systems they had 10 years ago and they are not exploiting them.

The London Hospital implemented real time systems for order, communication and results reporting for things such as pathology tests in the early 1970s. Many hospitals still don't have them now. Some systems are pervasive, such as GP record systems, but this tends to be the exception.

She followed this by posing the question as regards transforming healthcare. Previous attempts have not achieved the performance improvements that were sought; why should it be different this time around? She said 'We have many of the elements that we need. We have a vision. We've also got standards, the framework and other aspects including the funding.

'We have a workforce that is hard working and who will be willing to change if they see the benefit. The question is though can senior management pull it all together? We've got the management tools and techniques and we have information systems - although they are not perfect their innovative use makes them good enough.

'We have got more than enough to perform change and transform services: the information systems can improve as we go along. But can organisations pull all this together? Locally, if we don't bring all these things together then it won't work.'

Added to this she said that an holistic approach was required with all elements working together to achieve performance improvements. She said that 'for example there was no point informatics trying to enable a change in one direction when the budgets were encouraging maintenance of the status quo'. Also the informatics tail must not wag the transformation dog: IT and information enable and support the needs of the business. She finished by posing the question: have we got everything to bring it all together?

The debate

One of the first points raised is that the NHS is a chaotic and rapidly changing environment to work in. Other participants added to this by questioning whether they should work with chaos or try to fix it? This was followed by the rather damning statement that if you raise the bar, you get little reward as management raise the bar again. The NHS doesn't do reward systems very well claimed one person. People who work in the NHS aren't in it for the money. Another person added that if you excel then the system is against you. The finance system was also labelled as a disincentive to change.

People fight fires and they then try something new. The NHS should celebrate people who transform things. In order to encourage transformation people need an incentive. GP fund holding was a good example of this and it worked well because the GPs could change things quickly. They could also guarantee the benefit. This was reiterated by the fact that GPs have capable systems and hospitals don't.

Another comment was that Foundation trusts are too big to transform and the incentives aren't there. People need to be incentivised. If you get the incentive right then people will change overnight. You need to work out the changes they need to make the most of the incentives.

Referring to one of the speakers, it was noted that the private model won't always work for the NHS. In the NHS you don't have the same vision and it's not shared between all the different areas. Added to this the current model isn't sustainable.

However, when it comes to transforming, a lot of the time it is dependent on having enough staff. According to one person you need 3,000 staff to make change happen in a health community - although this wasn't the case with transforming the way that GPs work. The trouble is there simply isn't enough money to employ the staff. There was also some concern that the contracts in the NHS are hard to work to.

People want standardisation - not in some things but all things. Some things should be done locally and others nationally. People need to achieve their own mix of things. It was commented that people should be able to personalise which standard components they use. In the NHS the current situation is a one size fits all system that people will always find a way around.

There are also consequences of too much choice. People want control but they should not have total control because they don't need it. There is also a case for not bringing everyone down to one level, those who are lagging behind need to catch up. Then there's the issue that people do get attached to the systems they have been involved in designing and the equipment they already have.

Things only transform when people want to adopt it said one person. The key to revolution is don't put your money into just one area. When you have the systems in place, that's all well and good but how do you get people to use them? One suggestion is that the NHS needs early adopters in order to coach others.

People need a reason to transform and a push or a pull, then an incentive, commented one participant. You need agility, a tolerable amount of time and then you need some experience. On the opposite side of transformation there is a view that people should stick with what they have got, put it in place and not just talk about it and wait another 10 years.

You should not transform for transformation's sake. Think about what are you trying to achieve. It's about leadership and about what you want. You need people who are the right calibre as your leader; you need people who understand it. These are the things that are not in place.

The transformation challenge is not the change but to transform and continue to transform. What is the balance between the leading edge and the majority? It's dependent on the confidence of the client. If confidence is lost, it's the patients who will suffer.

It was agreed that in the NHS people need to use sticks and carrots to make transformation work. NHS is not one organisation, the NHS is different to a lot of other organisations. There is a different culture. If it works in one place, it won't always work in every other.

With the NHS, its problem is that it's very complex. It's a bigger problem than in other areas. Maybe transformation is already happening but it's been soaked up and nobody's noticed? Don't underestimate the value of incremental change. We should not try and manage it like a normal organisation.

One point that was made several times is that the NHS is only national in name - it's a lot of independent parts. People often think that the NHS is one large organisation but in fact it's more like a shoal of fish that looks like a whale.

April 2008