NHS System Governance

The English NHS is in for further reform as the flurry of consultation documents and the White Paper evidence. Overall, NHS reforms have been generally weak in having a thought-through systems governance approach. I think in part this arises from perceived problems with two areas: the role of the private sector: the systems governance of previous reforms has tried to ignore this sector, and in effect partition the health market certainly in England, with the result that a single playing field for providers couldn’t emerge. This was compounded by the previous government’s views that NHS providers could fail twice before being of public concern (a silly and ideologically driven position). The second problem has always been the purchasing side (a.k.a. commissioning), where there has been over the years feare of ‘letting the market rip’ (as if we somehow markets are generally regulated anyway), anxiety about purchaser impact on provider viability (again an ideological position on the how to deal with failing public institutions — the usual response it to prop them up with more money). or more generally a plethora of initiatives (such as World Class Commissioning — I wonder when this one gets buried?), whieh exuded more style than substance.

And so it continues with a failure, I think, once again to get the commissioning side of the health system balance sheet cleaned up.  One of the key things that needs to be central to systems governance is clarity of mission of the various bits that make it go, and how conflict is managed, mainly for systems-level problems that need to be resolved within the system, rather than constantly being taken back into the political machinery for resolution. Given that the coalition government wants to create some distance between the Department of Health and the regulatory oversight structures themselves (Monitor, CQC, NHS Commissioning Board seem the main statutory bodies here plus the GP Consortia and providers as agents), the possibility of conflict emerging between the Board and the other two regulators is real.

The NHS Commissioning Board will have oversight of GP Consortia, and in effect givea them a licence of fitness to practice; though this isn’t the exact terminology used, the Board does decide if GP Consortia are handling financial risk well, within the overall clinical frameworks and other guidance. And what of failing GP Consortia?

I am troubled in particular that the Board will be commissioning services for primary care and for national and specialist services. This is where the core problem for system governance lies, as the Board has a potential serious governance conflict between its oversight and regulatory role and its activities as a purchaser (sorry, commissioner…).

Who oversees the NHS Commissioning Board’s commissioning and why should anyone trust them to do a good job in absence of suitable oversight — are they not both poacher and gamekeeper? Since the Board will be commissioning, and also overseeing commissioning by GP Consortia who must commission within the any willing provider framework, will the Board be similarly constrained? While GP Consortia’s behaviour is subject to oversight by the Board in respect of commissioning decisions, the Board appears not to have any oversight in this respect (apart from the usual warm words that folks will consult and work in partnership, etc.) My worry is that the collective effect of GP Consortia commissioning may have some relationship with the desirability or not of specific national or specialist service commissioning. I am also worried about the logic underpinning what national and specialist in fact are, as this type of thinking is really ‘old school’, and is a remnant of centrist thinking. The epidemiology and service logic at work here could also find itself at odds with the possibility of unbundling and decentralising or otherwise restructuring such services (where capabilities, technologies, and opportunities present themselves), a possibility that innovation might unleash, but which cannot be anticipated by this particular solution. As well, we are too aware of the failure of prestigious providers to fail in their quality (do we need to mention neonatal heart surgery?)  So the assumptions underpinning the centrist logic of national and specialist commissioning should fall both within the remit of CQC and Monitor and under the wing of GP Consortia.

The proposed NHS System Governance System, 2014

Apart from all the other things that the Board will do (a very long list) adding into this mix managing commissioning relationships with providers seems not just a task too far but a source of considerable and likely conflict. This is to say absolutely nothing about how they will handle the commissioning of GP and other primary care services, which entails commissioning services from people that, in an different guise as GP Consortia, they in effect regulate.

How to do that? Well… Critical to effective commissioning is ensuring that adequate analytical capacity exists at the levels at which decisions are being made. If, and I see no reason to doubt this, GP Consortia do their jobs well with excellent analytical capacity to inform their decisions, they can, in some collective form, create an appropriate structure to handle the commissioning of national and specialist services. This will ensure the better integration of commissioning decisions, smooth the flow of patients and resources across the borders of GP Consortia, and clarify referral protocols. It will ensure that these national services are really national or specialist and are governed by common standards of regulatory oversight. Importantly, it avoids the potential for gaming the system, as it removes an incentive for providers to lobby for the creation of national or specialist services as a way of protecting their service infrastructure, and ensures that any complacency in service quality improvement is avoided by being able to for specialist providers to forum-shop for a regulator.

A herd of leaders charging an outcome

What is this loud thundering I hear across  England as people begin to adopt the new thinking on the English NHS from the coalition government?  Not a year ago many of those same people were saying quite different things. What has changed?

Golly, but now they are all trumpeting the appropriateness of outcome measurement in the NHS, something that should have been the case decades ago, but got hi-jacked by bureaucracy.  As I have said elsewhere, the patient is the most disruptive force in healthcare, and as the ‘auditor of one’ can drive quality and service integration in ways that top-down monster plans never could.

I’ve worked on developing outcome measures, and perhaps the one thing that is important to realise they are best developed as emergent measures from within the delivery of care as much as designed by a room full of experts and some evidence base.  My preference is to develop a system using something simple like a balanced scorecard, (with perhaps 4 to 6 critical measures under each of these four headings, so around 16-24 measures), something like this:

1. Measures about how well the healthcare commissiong process interprets healthcare requirements, and how well a provider responds to manifest demand for its services. [Measures here focus on the ability to interpret the dynamic nature of the healthcare environment.]
2. Measures about how efficient a healthcare provider is in organising care, including interconnectedness with other providers (handling referrals across institutional boundaries). Also measures of how effective commissioning processes are. [Measures here focus on efficiency, doing things well.]
3. Measures about how effective a healthcare provider is in delivering outcomes, including with other providers (integration of capabilities linked to specific desired results). Also, measures of how effective commissioners are in what they do. [Measure here focus on effectiveness, doing the right thing, mindful that the right thing has always been about outcomes, not outputs.]
4. Measures of how well the various health system actors such as commissioning bodies, consortia, providers, professionals, patient groups, etc. learn how to improve what they do, including driving forward change, introducing innovation, learning from mistakes, and developing solutions. [Measures here focus on ability to evolve, innovate, learn, change.]

None of these require central thinking and with properly strategically managed organisations would have been the norm, but for the various distractions over the years). They can be developed into an hierarchical performance model to tie together what individuals do, what processes are used, and how organisations institutionalise practices to achieve outcomes. (There is a cognitive model at work here by the way.)  This puts the measurement focus onto individual organisations, and not onto arbitrary aggregates (such as regions); the focus also requires much stronger strategic abilities within the leadership of system actors, and greater operational attentiveness by everyone. Hospitals, GP Consortia will need much improved analytical and operational research capacity within their institutions in order to more accurately interpret their local environment and respond in a timely manner; this important capacity has been held higher up in the NHS (in all its devolved parts) and indeed important operational research capacity and mathematical modelling seems the preserve of the Department of Health, whereas the problems are at the front-line. Shifting resources to where they are needed removes top-down performance management as the focus is now measuring performance in terms of delivery, not activity. Keep in mind, too, that as a complex adaptive system, there are no ‘strings to pull’, and that does change the nature of any information that is reported.

Change always requires that individuals learn to behave differently. Organisations are how we group together the behaviours of people to achieve certain goals. It is importnat to understand that:

1. Some people have trouble altering their behaviour, especially if it requires initiative and originality which in the past was not rewarded — so they may need either help or perhaps counselled out, particularly if they are in leadership positions (and beware the recycling of failed leaders);
2. Some goals may not require some organisational arrangements that are currently used, and may need to be changed (think of the potential disruptive potential of e-health); but people have a great deal of difficulty with ‘creative destruction’ of publicly funded institutions, which is why public service institutional renewal can be so difficult.

No one said all this would be easy, but it should be done better.

I just hope that great thundering herd is also thinking as it charges along.

Bureaucracy by Magritte

The well-known organisational practice of delaying has emerged as one way to achieve public sector austerity. This is to be aplauded, not regretted as it is applied to the English NHS. In fact, those looking to the total costs of running health systems should be taking serious note of what this is all about.

Public sector work has tended to favour layers of bureaucracy, to respond to the tendency of civil servants to do what is called rent-seeking, which in the end means building empires, or expand a sphere of influence. In the regulatory context, it is called regulatory creep, as mandates are progressively, but subtly expanded by rent-seeking regulators.

The end result is large spans of control for civil servants, but little actual progress in achieving public sector objectives and goals. This stifles creativity and further rigidifies individual behaviour into highly structured ways of working — further compounding the potential waste of public money.

In addition, the tendency of bureaucracies to create bureaucracies means that individual jobs are often highly compartmentalised from other jobs, as individuals carry specific dossiers or briefs. The compartmentalisation of government into ministerial portfolios adds additional barriers to sharing work, ideas, or insights across government, further compounding the opportunities to deliver better value for money.

The White Paper on the NHS plus the overall behaviour of the UK’s coalition government reflect a consistent and simple message about the way the public sector should be organised to undertake its tasks. De-layering means removing non-value-adding levels of organisational bureaucracy, layers with the sole purpose of either move information up (or down), or checking or verifying the work of others.

The NHS itself has been too long likened to a supertanker, but a school of fish is what we want — nimble organisations that can respond quickly to change. Instead, some commentators have questioned the proposed reforms, asking what will happen when you need to pull some strings centrally to get things done? What these commentators don’t realise is that healthcare is a complex adaptive system, which means that there aren’t really strings to pull.  Decades of belief in this assumption has produced ill-thought out control mechanisms, and inappropriate and pointless layers of supervisory control (such as Strategic Health Authorities), which really can be only weakly effective at best and destructive of initiative at worst. It is not unusual for SHA staff insert themselves into processes to assert  a measure of control reflecting their priorities, ignoring the real needs of people dealing with a front-line challenge.  Indeed, the rent-seeking behaviour of these quasi-civil servants challenges the validity, the very authority, of those who own the front-line problems in healthcare to actually solve these problems. Before all this, we had the failed Modernisation Agency, the failed NHS Training this, or NHS University that.

The insights in the White Paper have put paid to the assumption that overarching control mechanisms can work, putting the onsus on problem owners to solve these problems. There are proposals in the While Paper which accept the need for flexible and dynamic responsiveness to the local and real-world interface between the patient and their care provider. Many in the NHS will fail to understand this, and as in any organisational change process  there are some people who ‘don’t get it’.  By and large, failure to alter personal behaviours is a recognised barrier to implementing reforms, and many such people will need to be shown the door and encouraged to pursue other careers. The NHS often forgets to bury its dead and it frequently eats its young, meaning that failed bureaucrats get recycled and good ideas destroyed by a controlling culture.

I have immense confidence in the ability of the right people to solve the problems, (indeed of the ability of GPs to ‘get it’). There are also real challenges for the chief executives of the foundation trusts and other NHS providers to demonstrate the necessary leadership and management skills to drive out the costs and inefficiencies that are shot through the system; CEOs will be particularly challenged as they must now actually manage, and not simply administer a publicly funded entity and avoid rocking the boat.

There are too many quangos and other organisations around staffed with individuals from failed agencies so one must be vigilant to ensure that the delayering process does not just turn into a recycling exercise.

Want to know  more?

Charles Perrow’s important work, Complex Organisations, highlighted the hierarchical structure of professional organisations and asks important questions about how and why we construct overly complex organisations, and why they can become dysfunctional.