Success means different things for different trusts

Not for the first time in my 38-year career in healthcare, the NHS is under the spotlight. And the underlying − sometimes spoken, sometimes unspoken − question on politicians’, the public’s, the media’s, even our own lips, is: “Right now, is the NHS failing or succeeding?” Understanding and dealing with this question in relation to any organisation is the starting point of my new book, Too Good to Fail?

‘To get out of failure you have to know what you are failing on and what it means to succeed’

When I first took on a troubled hospital I realised I had to answer this question if I was to work out what needed to be fixed. Since then as I have managed a range of other trusts I’ve also realised that, if you are failing, to get out of failure you have to know what you are failing on and what it means to succeed.

Crucially that means understanding what others think is success, which is not necessarily the same as your definition of the term. Tracking and dealing with the difference between actual and perceived performance is pivotal to managing successfully.

All obvious? Well let me give you some examples of why it isn’t.

Measures of success

Roberto Mancini was sacked last month as manager of Manchester City. The failure? Only coming second in the Premier League, behind one of the world’s most successful teams, Manchester United. Roberto Martinez is expected to be appointed manager of Everton, a team at the top end of the same dvision, as a result of his success at Wigan. What was that success? Avoiding relegation over the last few years by a hair’s breadth and finally succumbing this year while winning the FA Cup.

It’s a no-brainer really. The measures of success for the different clubs are quite different − and it is critical to know not only that, but also who is making those measures.

And so it is in healthcare. Medway (a great hospital with great staff incidentally), which I took on in 1999, was a Wigan, with major overspending, long waits and large quality and safety concerns. Great Ormond Street Hospital, which I now manage, is a Manchester United. Each needs to understand and meet its own measures of success, judged by those who matter most to them, otherwise they risk failing.

In the nineties, Great Ormond Street came close to falling over as an independent organisation, not because it failed to be a Manchester United, but because it risked failing to be a Wigan − in other words, getting the basic essentials for NHS survival right.

Today at Great Ormond Street we are financially sound, meet our NHS targets and support our partners in the wider NHS as a secure level 4 (financial risk rating) foundation trust. But we have to keep that up and to really succeed in what is reasonably expected of us as a leading institution, we also have to be national exemplars in our results and behaviours, and excel on the world stage. So do we?

I haven’t space to give a full catalogue but here’s a flavour:

• world firsts in areas such as paediatric tracheal transplantation;
• work with children with speech problems that led to discovery of the gene that enables us to speak;
• magnetic resonance imaging enabled non-invasive “cardiac catheterisation” and post mortems (and many more procedures); and
• quality measures and mortality rates that are among the best nationally and internationally.

So, we appear to be cutting the mustard. But unless we keep at it, we won’t be.

Behind this, lie two other key points: best isn’t good enough and perfection is a delusion. You have to keep getting better and you can only do that if you recognise you are imperfect.

In my book, I explore failure, its causes, roots, patterns, cures and how to avoid it altogether. If you think you are being judged on mortality rates but are actually being judged on waiting times, or if you think you have to get a new hospital when it’s actually your infection rates that are key, then you will get into trouble. I show that trouble cascades into failure when someone realises they have a serious problem but doesn’t own up to it or actively conceals it, thereby almost immediately making it much worse.

The comeback

So what’s the way back? Honesty, for starters, then a communication blitz, finding the root cause, relentless persistence, managing the unknown by turning randomness into patterns, dividing aggregate problems into specific, practical elements, approximating, restricting your priorities − but, above all, doing something as soon as your insight is good enough.

Finally, back to the starting point. Is the NHS currently failing as some commentators would have us believe? I don’t think so, but we have reached the point where we are asking the right question: “What type of failure are we facing if we don’t do the right thing?”

‘For every complex problem, there is an answer that is clear, simple − and wrong’

Out of that is coming the realisation that the current issue, manifested in long accident and emergency waits, is a problem of the failure of the whole system of care, individual hospitals. Finding this out opens the way to identifying the right root cause, which is critical to finding the right, sustainable solution.

For me, GP out of hours services, the inability to discharge patients in a timely fashion, the lack of a 24/7 service and the lack of capacity, all need resolutions. But they are symptoms, or indicators that we need a better system, not the root cause of the problems we’re seeing.

For me, the cause is the lack of unimpeded patient flow through, and crucially across, organisational boundaries. We must encourage this, we must enable it, we must require it. As an analogy, perhaps you shouldn’t have motorways as they only encourage car usage. Once you’ve got them, however, you should do everything you can to prevent them clogging up with traffic jams.

Lest you get the impression my book is full of simple, easy solutions to healthcare − and indeed all management problems − I’m afraid it isn’t. In the words of HL Mencken: “For every complex problem, there is an answer that is clear, simple − and wrong.” Shoulders back to the wheel, then.

Jan Filochowski is chief executive at Great Ormond Street Hospital Foundation Trust. His book, Too Good To Fail? How Management Gets It Wrong And How You Can Get It Right (FT Publications), is available from bookshops and on Amazon.co.uk