A better kind of change

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The decision by the UK coalition government to reorganise the National Health Service is all too familiar. For cash-strapped organisations, public or private, restructuring is a kneejerk response. Politicians and managers, aided by consultants, hatch a grand rationalisation scheme with spreadsheets showing how much it will save. The troops are handed a “road map” with a destination and told to devise a way to get from here to there.

Such initiatives often fail (in the public sector, think of the horrors of the merged HM Revenue & Customs, a flagship of Labour’s public service reform, whose head had to apologise recently for saying that tax errors were normal). The costs of reorganisation – £3bn ($4.7bn) plus £1.2bn annual running costs for the NHS, according to one estimate – are invariably underestimated and the benefits exaggerated. So the sorry cycle begins again. For the NHS, where demand forever outstrips capacity, reorganisation literally never ends.

Failure is usually blamed on entrenched interests and poor implementation. But the tautology of the conventional remedy – better planning, better implementation – ought to signal a warning: when the only answer to repeated failure is to do the same failed thing yet again, only better, you know there is something badly wrong with the premise.

Devising a road map for change is as futile as preparing one for a football match. As Henry Mintzberg, the academic and management writer, put it: “Setting oneself on a predetermined course in unknown waters is the perfect way to sail straight into an iceberg.”

Change is utterly dependent on context. Once the variables that make up complex change are in motion, they interact in ways that no one can control. Unintended consequences all too easily swamp intended ones. Planning a precise destination in advance is thus worse than futile – it makes no sense.

But this does not mean that all change is doomed to failure. We just need a different kind of change. Thus when Steve Allder, a consultant neurologist, was confronted with his very own resource crunch in the stroke unit at Plymouth Hospitals NHS Trust, he started from the opposite end to Andrew Lansley, the health secretary.

As Allder recounted to a conference audience in November last year, in 2008 the trust’s mortality rates were worryingly high. The stroke unit could not meet good-practice guidelines and was far over budget, threatening the financial health of the entire trust.

Yet within a year, the position was turned around. With response times slashed, nearly 80 per cent of patients now spend almost all their time in the specialised acute unit (a key clinical indicator) – more than anywhere else in the country. Mortality rates are below the national average and falling.

Equally remarkably, the cost of care has halved. The unit now achieves vastly better results with 17 fewer acute and rehab beds. In three months, says Allder, the unit realised benefits equal to 14 per cent of the entire hospital budget. It no longer has a “resource problem”.

How was the miracle accomplished? The short answer: by analysing demand from the patient’s point of view and redesigning the work to meet it. Ironically, in fatter times the trust would almost certainly have built a bigger stroke unit with more beds. It only handed the job to Allder because although he could not predict the detailed outcome, the data told him that resources were not the problem – it was how they were used. He knew that the incidence of strokes was extremely regular: an average of 550 Plymouth citizens suffer a stroke each year – a rate of 1.5 a week.

That was a good start. But it took much more sifting of the demand data to make the breakthrough, which came when Allder realised that not all stroke patients were alike. The most challenging and costly cases were those who had suffered a severe stroke – logical enough, but not a distinction that had been made before.

When that clicked into place, the team quickly designed a new end-to-end clinical pathway for these victims, dramatically improving their care. Improvements were also made to the management of the other subgroups. “Looking at patients through an end-to-end lens has completely liberated the way we manage them, and that underpins all the benefits we’ve seen,” Allder says.

A one-off? Yes and no. This may be the first documented exercise of its kind in the NHS, but the approach – careful analysis of capability and redesigning it around known demand, focusing on value and quality to consumers – is hardly new. The November conference heard success stories from local government, charities and financial services. Allder believes spreading the methodology across the NHS would yield productivity gains of at least 20 per cent. “Demand across every condition coming into a hospital or GP is incredibly stable and consistent,” he says.

So what about other services fighting resource constraints – police, housing, social and children’s services? The signs are that the same is true there: the resource problem is within. Because each case is different, it is impossible to predict the exact result of change implemented in this way. But it will certainly be better – which is not something that can be said of Lansley’s colossal NHS gamble.

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