Shine the light on what needs to change and the NHS will improve

I wrote an article last year arguing that NHS commissioners and providers could both benefit from abandoning the “checklist” culture and learning to trust each other.

‘The system, interrelationships and worry about making sure activity is seen for money spent is obfuscating the achievement of goals’

The more checklists we apply, the less we trust; consequently driving up transactional costs.

I reasoned that we could professionally trust each other and make agreements based on a desired effect, trusting all parties to deliver it the best way they saw fit using their expertise; saving money in the process.

Today, trust in each other is needed more than ever. There is an endless amount of change we can do to improve the NHS. It is fundamentally inefficient despite enormous amounts of money under its umbrella.

Under the current harried, evolving system of clinical commissioning group, local area team, commissioning support unit and provider relationships, areas key to making cost saving change such as redesigning and improving services are becoming ineffectual.

The system, the interrelationships and the worry about making sure activity is seen for money spent is obfuscating the achievement of goals. The number of projects, checklists and their progress are often seen as the job in hand, and not actual achievement of goals – we’re over specifying.

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Bigger vision

For example, when you buy a new door, you have to precisely specify it, otherwise it won’t fit. Whereas a larger project like a loft conversion, you step back from the minute detail and ask for a loft conversion, maybe add more light with additional skylights etc. There’s no detailed measurements given to the builder, you leave it to them to do the detail.

What you do want is something that’s fit for purpose, giving you the result you want, the achievement of your goal. Surely changing a health service provision warrants a bigger vision rather than a detailed specification with its compliance checklist?

‘Detailed checklist culture hasn’t worked; we need a different approach’

Focusing on dictating detail and checking it drives up costs. Retrospective inspection drives up costs. It is also an acceptance that people or organisations cannot be trusted, and a layer of administration needs to be put in place to manage this failure or lack of trust. Detailed checklist culture hasn’t worked; we need a different approach.

One reason the NHS is inefficient in making change, rather perversely, is there are too many experts, all with strong opinions, which are usually right in their own way.

All the local experts mean a lot of local ideas and solutions are out there, competing for prominence and often leading to an aggregate effect if there is no change.

Big system sustainable change can be an impossible ambition, rarely achieved and ending up in a circulation of ideas.

Tools often get the blame for the “no change” net effect, when it’s not really their fault. Tools are just a means, a frame of mind, a culture – not an end in itself. It is perhaps best not to worry about “tool fads”; they are all there to lubricate change, leave it to people to choose their tools of choice.

Shine a light

So what’s the solution to a net effect of inertia?

Most solutions sloshing around the system are well known by local experts, who have niche knowledge of their field and locality.

Many improvement programmes fail or make little impact because they struggle to be implemented in the local setting, failing to recognise local population, local facilities and local history etc.

This is where the power of the “spotlight” can work. Conventionally when a spotlight is shone on someone or an organisation, the first reaction is defensive or protective – “we can sort this out ourselves”. This is often the nature of a provider-commissioner relationship, and it can cause tension between the two.

‘Focus on a worthy destination, not an appeasing journey’

But why not positively use this mechanism to mobilise local expert knowledge to come up ways of improving things: trusting them by their own means.

The spotlight operator needs to just shine the light, state the desired outcome – and perhaps a block cost for delivery – and check the vision is achieved. Focus on a worthy destination, not an appeasing journey.

In the days of attempting the land and water speed records, the more the spotlight was shone on the record, the more it drove human endeavour to find new methods and new equipment to gain the record and step-changes in technology were stimulated.

There is no particular spotlight on these speed records and therefore relatively fewer advances have are made. If the spotlight shines on the biggest number of raw eggs that can be juggled while hopping, there will be a great effort to attain that record.

The effort, method and solutions require the vision to aim for, not just being told or specified to just juggle three eggs. So it could be argued that the key is to know when and where to shine the spotlight, not worry about the resources and methodology needed to implement change; they will come as a consequence.

So combining a view of not checklisting or planning for failure, but using strong local expertise and knowledge, we could simply shine the spotlight on the area we need change and trust everyone get on with finding a way to make it happen.

Take the tick boxes away and let the existing skills and expertise develop. If the government wants to reduce regulation by a third, this is perhaps a move in the right direction.

Mike Mayers is head of business processes at Stockport Clinical Commissioning Group