Why no inspection & failure regime can save NHS

We have a new robust inspection regime from today, and we’ve just had another list of failures, sorry “special measures”, for 11 unfortunate hospitals.  That leaves 93% of hospitals breathing a sigh of relief, and I’d bet a good 93% of the people in the 11 are doing a good job, feeling a lot worse about it today than yesterday morning.

So what?  If those so labelled 7% improve a bit so they are just good enough to “pass”, what will that do for the performance of the NHS as a whole?  I doubt we’ll even notice.  I doubt we have measures sensitive enough to tell the difference.  The very best we can hope for is that a few bad things are more difficult to get away with, but the history of the human race, let alone the recent NHS, says there are others who will fill the vacant spaces.

The average hospital is untouched by any of this.  Yet as we are endlessly told that a total transformation of everything is needed right now, it’s the average hospital which has to move.  Our obsession with failure leaves them untouched.  The Keogh review had another way to pick outliers, which CQC never spotted, and even told them not to focus on what Monitor says but do quality instead. (Ha!)

Failure can be serious, harms patients and needs to be overcome.  But this will not save the NHS.  We are told by NHS England that bold thinking is needed to address the £30bn funding gap forecast in the next few years.  Finding failure, by whatever means the outliers are identified, will never do this, and worse, the focus on failure hurts the very change we need.  Last week’s annual report from Monitor features “compliance”  53 times,  ”innovation” just once - to say that their oversight regime should not inhibit innovation.  Ahem?

Find positive outliers

High performing bunch

You want to develop a national cycling team, to be world leaders.  I think you’d spend your time scouring the cycling clubs of the country, looking for the fastest and most promising.  Then you’d hone their natural talents, bring in the best sports scientists, facilities, training regimes.  An interesting thing happens - they get closer together.  Britain’s best cyclists, and the worlds best cyclists, cycle at almost exactly the same pace. 1% difference in the Tour de France looks like a chasm, though it’s almost nothing.  On a club race, the last in may be 200% behind the winner.

This tells us something fascinating when we don’t know what good performance is like.  Measuring a health service, or hospitals, or units within them, produces figures, and let’s say we have no idea what merits “good” performance.  If there is a broad spread across many units, we can surmise that the average is not particularly good, like our local cycle club.  So long as there is no target involved, if all of them are very close, they are probably very good.

Most of the time, we’ll find high variety.  Some is due to the environment, so let’s be aware of that and correct for it where possible.  Now look at the positive outliers, the very opposite from finding failure.  Ask them what they do.  Go and find out.  What do we discover?  Methods, thinking, leadership, system?  Herein lies gold dust.  Where common methods are linked with superior performance, we have found something to make a positive difference to outcomes.  The next steps are obvious:  help the positive outliers develop and describe what they do.  Cross pollinate between the best performers further to improve.

The tricky bit is getting the average performers to do something different, as described from the high performers.  It’s a no brainer, we all say, and we’re right.  But the average people are telling us how it’s risky, can’t fly, won’t work here, because we’re different and so on.   Press on - no one says this is easy.  But it has to be done if we are to make any dent in £30bn.

Does it work?

Exactly this approach led to the discovery of the Patient Access pioneers, GPs who had invented an access method where every patient initially has a call from the GP, and is always offered a same day face to face appointment where needed.  Read the story of how it came about.  From that start the method has been refined and the number of practices has doubled in two years.  Case studies tell of rapid and transformational change.

What about hospitals?  The first thing is to find measures uncorrupted by targets.  What looks like close bunching doesn’t count if there is a target involved.  All hospitals are bunched closely around 95% of patients being treated within 4 hours, because the establishment drops on them if they fail.  This kind of bunching hides wide variation in performance, but a different measure exposes variation.  Look at how long patients wait in A&E to be either discharged or admitted on our searchable charts. More about the method in a previous blog.  This is only one measure, says nothing specific about clinical outcomes, but it could be an important pointer to  the kind of positive outliers whose methods can be refined and transferred to all providers.

How much does it cost?

Peanuts.  The first step is already done for you.  Go and see.  You don’t need legal teams to work out what revelations can be published.  You don’t need rebuttal teams to explain how it was all down to the previous organisation/government/management.  You don’t even need to write a report.  You don’t need an extra £25m per year.  You won’t hit the headlines.  In fact, you’ll work damn hard to get noticed.  But you might change the world.  Just do it.

One Response to “Why no inspection & failure regime can save NHS”

  1. Great article. Atul Gawande dealt with a similar theme in his New Yorker piece about the Cheesecake Factory(https://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande). My favourite bit is when he asks a restaurant manager what he’d do to healthcare:
    I asked him what he would do if he were the manager of a neurology unit or a cardiology clinic. “I don’t know anything about medicine,” he said. But when I pressed he thought for a moment, and said, “This is pretty obvious. I’m sure you already do it. But I’d study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute.”

Leave a Reply