What about the NHS’s culture?
Civitas, 30 April 2009
In all the talk about what the NHS is going to have to do with its tighter budgets one thing seems to be missing: the underlying culture of the organisation (or, more accurately the organisations that make it up). Discussion is focused on structures, processes and levers that the NHS has, or doesn’t have, at its disposal to drive efficiency.
Perhaps this is unsurprising. In times when in the next financial year the NHS will need to contribute £2.3bn of the £5bn public sector efficiency savings; and thereafter can expect real cuts in spending for at least four or five years, it is natural to focus squarely on finance.
The opportunities being discussed are familiar to anyone in health policy: controlling the prices paid to hospitals under the payment by results tariff (perhaps a best practice rather than average practice tariff); freezing (or decreasing) health sector pay; reducing costly and significant variations in practice (up to £3bn on offer here according to the NHS Institute); ‘productive wards’ (read lean thinking); the foundation trust finance regime; service-line reporting; and, of course, ‘world class’ commissioning (more allocative efficiency in the economist’s jargon). We may even throw what competition there is in the system in.
All, of course, if pursued would have a significant impact. History also tells us that the NHS tends to get more productive when finances are tight. However, history also tells us that cost-cutting has typically been achieved through salami-slicing and a centrally-driven and almost Stalinist approach rather than going about things in a smarter way. Look only at the fiasco over NHS deficits ‘crisis’ in 2005/06 when funds were rapidly increasing! The unintended consequences of this have been significant: morale is crushed and quality is too often compromised.
Instead, those in power would do well to have a closer look on the literature around quality improvement. The first thing to realise – as, to be fair, Lord Darzi has emphasised – is that high quality care is not necessarily more expensive. The NHS wastes millions (sorry, billions) in replication, poor care management and patching up its own mistakes.
The second, is that quality improvement (in both clinical outcomes and efficiency) is as much a function of the underlying culture, emotion and politics of an organisation as it is about ‘hard’ things such as structure and technology. This is unsurprising when you think about it. Very little is achieved in life without passion, which is why top hospitals and top companies devote huge amounts of attention to staff satisfaction. Happy staff = happy customers. As Paul Bate and colleagues concluded in a brilliant book tracking the quality improvement journeys of hospitals:
We should perhaps be spending more time developing professional and corporate commitment than directly trying to improve quality: programmes or projects quickly run out of energy; being professional is a lifelong vocation and the very fuel of giving service.
We must and we should. Command-and-control can only achieve so much; what you really want is clinical engagement; staff taking the initiative themselves in leading the drive to quality and efficiency. Unfortunately, this is not something the NHS has worried too much about in recent times: central initiative has ruled, ok. The most pertinent example of the ill-effects of this is Mid Staffordshire, but don’t go thinking this is an isolated problem. In the latest staff survey by the Healthcare Commission just 39 per cent felt that they worked in well-structured teams in which staff have clear objectives, worked closely together to meet these objectives, and regularly reviewed and reflected on performance. Oh dear.