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Rubbing the lamp


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Friday, 13 March 2015

Rubbing the lamp

The NHS needs to change. Most people get that. It needs to change fast because the gap between resources and demand is growing fast. Somehow, we need to “find” £30bn by the end of the decade. We’ve pledged to save harder and, in turn, politicians have promised to dig a little deeper, but everybody knows that these are not the answers.

The answer is transformation. Change is small and loose. Transformation is big. Three whole syllables bigger, in fact.

Change is often gradual, but transformation is dramatic. It’s the difference between planting a few seeds in the hope of one day growing some flowers and waking up in the morning to find a giant beanstalk outside your bedroom window.

Skip to the end of the story. Thud! There it is: a big bag of gold.

What are we going to do with the £200m transformation fund? There’s a serious risk that a lot of it will go to waste. Here’s why.

First, we’ve been here before – we just called it something else. We’ve had pilots, champions and pathfinders, to name a few. Now we have vanguard geographies. The architects of these projects have a primitive faith in the power of names. Bin the thesaurus: they don’t make any difference.

Second, novelty is not the same as innovation. When the NHS talks about innovation it means trying something new or showing something off. We often hear of innovation showcases, exemplars and demonstrators, the purpose of which is to do find a brilliant new way to do something, so that everyone else can copy it. This is to innovation what the X Factor is to musical composition.

Third, innovation is the wrong goal in any case. Ask patients what they would like from the NHS. Innovation won’t appear anywhere on the list. And no, the NHS approach to innovation doesn’t create the things they do want either.

Innovation in the real world involves backing several ideas knowing that only one or two will succeed. It is an efficient way to produce a new gadget, but a wasteful way to improve healthcare services.

We know the answers to the questions about what kind of services we want to provide, but if we want to move out of the Legoland of new models we need another set of questions.

Does the organisation have the skills it needs? Is there a competent senior team? Are the staff up for it? Does everyone know what they are supposed to be doing? How will they set about creating a brand? What about organisational culture? Who are the competitors? How will it manage growth? When might it need to seek further investment?

The people leading the programme told the HSJ:  “What we’re going to do is have real time improvements on a monthly basis. We’re not going to say ‘in three years’ time we’ll do a full evaluation and see if it has made a difference or not’.”

Tough talk from the same channel that brought you the double act of Scale and Pace. If you want big transformation, you can’t have it fast. Only David Copperfield can turn elephants into aeroplanes before our eyes.

The magic ingredients in transformation are investment and time. Viable organisations where different professions work in harmony to deliver fabulous healthcare will not spring up a few months after the sprinkling of the magic beans. They will take years to form. The right time to start evaluating a new business is after about two years. Real-time evaluation will only get in the way.

Politicians and NHS England managers would throw up their arms in horror if you suggested that a transformation fund should be used like venture capital, but that’s exactly how it should be done.

The criteria for evaluation are very simple, in fact there are just two: does it serve the needs of patients and will it keep going under its own steam after the funding has run out?

It’s time to stop wishing and hoping. If we could summon the Transformation Genie we’d have done it by now. Rubbing the lamp harder won’t help.

Editor: Julian Patterson

On Twitter @jtweeterson

Philip Coulthard
Philip Coulthard says:
Mar 13, 2015 12:34 PM
As a frustrated social entrepreneur seeing huge waste in the NHS, I ask you to dust off your copy of Schumacher "Small is beautiful" page 204 /5, and reread the subject of Subsidiarity. Then please turn to the VSM from Stafford Beer web link below.


For every "Expert" administrator, making key decisions could you please consider an entrepreneur for a second view?
Anonymous says:
Mar 13, 2015 12:38 PM
Excellent article and, in my opinion, an approach to the NHS which needs to be seriously considered. The government need to stop using the NHS as a pawn in their political games and give staff the chance to voice where real changes need to be made instead of spending a fortune re-arranging the hierarchy.
David Perton
David Perton says:
Mar 13, 2015 12:47 PM
Spot on again Julian. We have to realise all the big ideas have already been impleneted and the medium scal changes are in progress. We are in the domain of ever dimninishing returns, against a backdrop of ever increasing activity, due to demographics and ever incresaing costs due to technolical improvements.

What we need to realise is we are backrupt, the NHS has providers making losses to the point they don't agree the PbR tariff and commissioners searching ever harder for QIPP savings. Management, NHS England, DH and the politions are bankrupt of ideas, not surprisingly, and the nation has a huge overdraft. If waste in the NHS was as endemic as some comentaters would have us believe, we'd be making massive savings every year, it simply isn't true.

Against this backdrop transformation is not possible, we need to keep gently rubbing the lamp to reduce waste & cost where possible as a continuous improvement philosophy and increase taxes to meet the spending gap.
Big Mach
Big Mach says:
Mar 13, 2015 12:51 PM
Great article and I pretty much endorse the sentiments. I went to a thing at Kings Fund in the week, Roy Lilley in conversation with Sarah Wollaston, chair of commons select committee. Quite interesting but came away with more (unanswered) questions. If you think the NHS makes decisions without an evidence base then it's entirely in line with government which makes policy with no evidence base either. Look for common sense, logic or the employment of universally accepted principles in any of this and you will find none. I've being doing this game for years and to be honest I'm bored, just happy to float along and ride the successive waves of reorganisation, repacking the same old same old and, for someone who loves the NHS and everything it stands for, that scares me.
Harry Longman
Harry Longman says:
Mar 13, 2015 01:01 PM
With his serious face on, just as sharp a scalpel as with his funny face. Is this any different? The language is about changing the way care is delivered, the means are familiar structural changes. We don't know. Will we know before they are either rolled out, without evidence, or killed off by a new regime?
Evaluation may take a couple of years, I agree, but measurement can and must start now, so we'll know how to evaluate, and if we get the measures right, we may know a lot sooner.
mark bradford
mark bradford says:
Mar 13, 2015 01:04 PM
Brilliant article: “Real-time evaluation will only get in the way”. When will people realise this? How many UCPBs, SRGs and other senior meetings are looking at granular measures month after month? When something is broken spend time fixing it, not analysing exactly how broken it is. The wasted time is heart-breaking.

It’s the same with transformation: we talk endlessly then suddenly jump to a solution, watch it “fail” like hawks for a few weeks and the whole thing peters out. Work hard to develop ideas (it’s a process - hard work, not shiny ideas), set them up and let them run. If your process is robust your ideas will be near the mark so give them time to evolve.
Philip Coulthard
Philip Coulthard says:
Mar 13, 2015 02:00 PM
It can only be expected that supporters will rush to the aid of the author. Yet no one asks the simple question of ...er, what savings have been identified? For example, on one type of equipment, in one trust, we identified £1M pa of potential savings in service revenue. We were not given the opportunity to compete for the work. I am aware these savings could have been made over the last 15 years. If you multiply that potential saving by the number of hospital Trusts you have a significant portion of the money you need to find. Could the savings be applied to other equipment? I believe the answer is yes. I post this as one example of an entrepreneur with intuition versus your intelligent administrators as described by Schumacher.
Anonymous says:
Mar 13, 2015 02:13 PM
I much prefer this more serious approach than the jokey one. This message is sensible and serious but the thought of trying to transform the NHS is daunting because it is so complex and huge. The various parts just do not seem to be joined up even at local levels. One step forward would be to simplify commissioning and procurement of services. One thing that needs to happen is for all GPs and other medical practitioners to be employed by the NHS and all the various payments for "extra" services just stopped. They should not be run as business because this has resulted in such a variation in the the quality of service. What you get is certainly a post code lottery these days. GPs should be treated like dentists and, if they have to go private to survive - so be it. Many charge for extras anyway. Furthermore, many hospital consultants run their own businesses while working in the NHS. The NHS should either employ them on a full time basis or procure their services on the basis of a fee for the number of hours given. Furthermore, they should be given more status by subsidiary staff and there should be a much stricter hierarchy in hospitals, as there was at the inception of the NHS. It is a mess at the moment. Patients cannot tell the difference between an orderly and a staff nurse. The whole system needs to be tightened up and stricter.
Anonymous says:
Mar 13, 2015 02:26 PM
Like most of the contributors here, I don't know what the answers are. But I make one point in this context.
We have been nurtured for decades in the belief that giving Choice in the public sector is a "good thing". Politicians bang on about it. We bang on about it. More choice!
But, by definition, true Choice means "An Excess of Supply". Providers have to provide more than consumers are ever going to need. Otherwise it is not true Choice.
So, have we provided real Choice? If so, have we implemented 'Oversupply' of our services? Is that where the 'hidden costs' lie? Is that where the elusive savings are to be found?
If not, then we really cannot say we are delivering Choice - and we should stop banging on about it.
On top of all that 'Choice', or lack of, we often see the familiar list: DH, NHS England, Public Health England and, and, and. Isn't that list an awfully long one?
As I say, I don't know what the answers are.
Anonymous says:
Mar 13, 2015 02:49 PM
It is bizarre that when there is so little money for true healthcare, the NHS is committed to funding large amounts of money for sperm donation, egg donation,and IVF even for male and female homosexuals, and for people whose relationships have failed and are single at the time of application. There are many treatments that are given because it is possible to have them, and not because they should be given. It's about time the NHS got real about what it funds. The whole system should be for promoting health. It should also be for health rather than just prolonging life at any cost.
Michael Shaun Rogers
Michael Shaun Rogers says:
Mar 13, 2015 03:33 PM
I wholeheartedly agree with this well thought-through piece. And it reminds me of the Petronius quote:
 “We trained hard, but it seemed that every time we were beginning to form up into teams we would be reorganised. … I was to learn later in life that we tend to meet any new situation by reorganising; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralisation.”

Carol Munt
Carol Munt says:
Mar 13, 2015 04:06 PM
Be fair, what about the innovative idea for SEVEN DAY SERVICES Anyone would think it had been done before.
Anonymous says:
Mar 13, 2015 06:18 PM
Surely there is a third criteria of is it better than how we are already doing it? I always find your articles frustrating. There are some seriously good points but all surrounded by negative "humour". But maybe it is because by the end of the week i have lost the sense of mine.
Anonymous says:
Mar 17, 2015 12:05 PM
You're right - we're all fed up with schemes with fancy names that ultimately do very little. So much could be done by simple straightforward approaches. I work with specialist nurses across the UK and we have recently been talking about the problems they have with a simple lack of admin/secretarial support. So a highly qualified Band 6/Band 7 nurse is having to type letters and do her/his own admin, which takes them away from caring for their patients, because their Trust won't give them a few hours dedicated secretarial time. Maybe it's because it's so simple and not 'innovative' or 'transformative' - but it would improve care and be more cost-efficient.
David Munson
David Munson says:
Mar 17, 2015 05:25 PM
Wooow. This isn't about efficiency (wringing more out of a hard pressed service) .... it's about appropriateness.
The greatest waste is sending patients into hospital when they should or could be dealt with in a community based service at a 1/4 of the cost.
Better still let's stop medicating for social problems.
Dr Chris Loughlan
Dr Chris Loughlan says:
Mar 17, 2015 10:50 PM
Perhaps an all too narrow perception of innovation. we have a very large workforce. how many of this workforce feel actively engaged with/in innovation. it can be defined as a 'frame of mind or thinking' to maintain or improve the quality of service. If we were to transform the way we valued ALL staff then it is highly unlikely we would have seen the recent critical breakdowns in care. As Berwick put it: culture trumps all.
Jo Wasley
Jo Wasley says:
Mar 18, 2015 10:49 AM
"The right time to start evaluating a new business is after about two years. Real-time evaluation will only get in the way."

May I respectfully suggest that if real time evaluation has been getting in your way then you haven't been doing it right. real time evaluation should be part of any sound approach to project or programme management. It isn't about collecting endless measures and performance monitoring, it is about making sure you have the information you need to make sound decisions whenever you need to make a decision. If it gets in the way of the momentum and success of the programme then it has been done really badly!
Julian Patterson
Julian Patterson says:
Mar 19, 2015 08:08 AM
Jo - the project is the business and transformation has to create viable businesses not programmes that switch off when the funding dries up. A start-up business needs to evaluate itself, but it wouldn't expect its bank manager or investors to be breathing down its neck or asking for a business case for every decision. History teaches that the people holding the purse strings will be under so much pressure to show progress that they set daft "reporting" and evaluation goals for the recipients. See Prime Minister's Challenge Fund for details.