In planning to restrict the NHS data available to NHS organisations, the HSCIC has jumped the shark

The HSCIC is planning to redact the activity information in HES (hospital episode statistics) for patients who have lodged type 2 objection to data sharing even when the data is shared inside the NHS. This policy is mad, will hurt the care given to those patients and will cause potentially huge chaos in other NHS bodies. It will also fail to achieve any increase in protection for patient confidentiality. If a clusterfuck had a child with an omnishambles we'd get a result like this.

A caveat before I describe what I think is proposed

My knowledge of what the HSCIC has proposed is based on a chain of chinese whispers that may have garbled some of the details. So some of what I say below may not be exactly right. I actually hope I'm wrong as the implications of what I've heard are catastrophic for NHS planning, improvement and patient care.

What has been proposed

The HSCIC currently releases comprehensive information about hospital activity (the HES datasets) for use by the NHS to plan and manage the system and to third parties (including drug companies) for research purposes. Those releases are only supposed to happen when the purpose is valid and the users can handle the data securely.

They are, apparently, proposing to remove the records relating to a large number of patients from any releases after january. This redaction of data will apply even to other NHS bodies who will now have incomplete data about what is happening in hospitals (GP data is irrelevant as it isn't collected centrally yet).

This proposal has profound and worrying consequences for the NHS. It is also entirely unnecessary. I'm going to try and explain how we got here, why it is so dangerous for the NHS and patient care and what should have been and could be done in the future to avoid the problem

How the HSCIC got into this mess

When care.data was first proposed as a way of joining up GP data with other NHS data about patients many people were very worried about their confidentiality. Eventually it was realised that some people would want to object to their data being used

The NHS collects a lot of data about patient activity. Comprehensive information about every admission, outpatient appointment and A&E attendance is gathered nationally by the HSCIC and released to other NHS bodies in several forms for the purposes of running the NHS. HES (hospital episode statistics) is one of the most important datasets and is used very widely (though perhaps not used enough given how valuable it is for care and improvement). The NHS has also proposed joining up this data with data about activity in GP practices which is currently not collected nationally. This is the highly controversial care.data programme.

The controversy over care.data raised a number of concerns about confidentiality and patient consent to the use of their data. The initial communication about the programme dealt with these issues very badly. As a result new proposals were developed to allow patients to record objections to their data being shared. A type 1 objection should stop any data leaving the GP. A type 2 objection was intended to stop any "secondary uses" of the data (I'll come back to what this means later). GPs started to record those objections a couple of years ago.

But since the data collection proposed under care.data kept being postponed nobody worried about those objections and the HSCIC did nothing with them. But the objections had implications beyond data from GPs. HES data on all patients has been widely shared for decades. The care.data controversy highlighted patient concerns about the use of that data for non-NHS purposes such as medical research or drug development. The apparent intent of type 2 objections was to allow patients to stop such uses of their data.

But the HSCIC did nothing and continued to release the complete data to organisations who requested it for valid purposes and who could show they would handle it securely. Then the Information Commissioner's Office (ICO) ruled that doing nothing was not an option and that the HSCIC would have to honor the objections.

The HSCIC response to this appears to be to remove the information from all releases of HES data even to other NHS bodies.

What type 2 objections mean and why there is confusion about it

The catastrophe the NHS is facing arises from three interlinked factors:

• What a type 2 objection means has been poorly defined and poorly communicated
• Senior policymakers, campaigners and others have shown an incredibly poor appreciation of what the NHS does (or should be doing) with data
• The HSCIC has shown a poor appreciation of the uses of its data and a chronic lack of pragmatism about ways to implement mechanisms to assure patient consent

The early results of care.data pilots suggest that nobody understands what a type 2 objection actually means. The current explanation of what people are objecting to confuses patients, the GPs who have to explain it to them and almost everyone else who has to deal with the consequences. The language talks about the uses of data for "direct care" and about restricting uses for "secondary purposes". But these are incredibly poorly defined terms (I've discussed the consequences of this in a previous post). What many objected to in the original communication of the purposes of care.data was the use of their data by commercial firms (like drug developers) for research or the possible use of the data in insurance or by other branches of government.

Later care.data pilots seem to have concluded that a simpler explanation of the objection (that describes it as an objection to sharing with bodies outside the NHS) is clearer and easier to explain. Fiona Caldicott's review in january seems likely to conclude that this is how we should communicate to patients and how we should interpret the opt-out. This is a pragmatic idea which creates a clear guideline for where data can be shared. The HSCIC have to do something before that ruling will be finalised, meaning they have to live with a fuzzy definition of what a type 2 objection actually means. They have, apparently, chosen the most restrictive and most damaging interpretation of it that prevents any data being used outside the HSCIC even in NHS bodies where the data supports direct care.

They may have been told to go with this interpretation by senior policy makers to send a strong signal that patient consent will be respected and to avoid the possibility of future legal challenges. But if the lawyers have recommended this as the best approach there is only one (Shakespearean) response: let's kill all the lawyers (Henry VI part 2, if you wanted to know the source). Even a data scientist can think of defensible pragmatic solutions other than this one that are arguable given the fuzziness of what the current type 2 objections mean (for example implement redaction for data shared outside the NHS).

But the most astounding thing about the idea of preventing even NHS bodies from getting this information is that the senior people who have recommended it have spent no time at all considering the damaging consequences. As far as I can tell they didn't even think they should ask any of the affected bodies whether there would be any adverse consequences if the data they get is suddenly corrupted by the removal of data. This suggests to me a staggering lack of appreciation of what the NHS does with this data.

This isn't helped by the same lack of appreciation shown by the HSCIC for how the data they provide is used. And a further lack of appreciation for how to ensure confidentiality is protected (it's not that they don't protect information well, it's that they seem to have no capability to explain those protections to anyone). The CEO illustrated this earlier this year when he said in a discussion about future data protection that he didn't see why anyone needed patient-level data (for the uninitiated: some analysis is impossible without patient-level information and much other analysis is difficult or incredibly time consuming without it). They also show their lack of insight when monthly flows of information change the date format for fields like hospital admission date from an international standard to an illogical mess creating vast amounts of extra work for the poor analysts who have to sort it out to do any work.

This lack of insight means they are a shockingly poor advocate for their customers inside the NHS when policy changes are proposed. They simply don't have the insight to know why the policy changes will affect anyone.

The collective lack of insight about how data is used combines with the fuzzy definition of what type 2 objections mean to give a policy proposal that will corrupt essential key data widely used across the NHS. And, as far as I can tell, no senior policy maker even thinks it is a problem.

The situation is even worse than that. The small group of people who came up with the idea didn't even talk to the groups who were most likely to be affected by it. Some of those groups found out what was proposed by accident. Rumour has it that many of those groups are now desperately scrambling to find workarounds that will enable them to continue their essential work. These workarounds will be expensive, may not work and will undermine the purpose of the HSCIC policy in a way that might terminally damage the organisation's credibility.

Why corrupting the data is bad for the NHS

It should be obvious that, if the data you have is incomplete, the decisions you can make with it will be wrong, perhaps very wrong. But if this simple observation were obvious the HSCIC proposal would not happening and certainly would not be happening without any consultation with the groups most affected by it.

But it is happening, so perhaps some basic explanation is required.

Imagine, if you can, that you are running a major supermarket chain. Let's keep it simple by keeping the role of head office to distributing the money and restocking the shelves. You need to know everything that has been sold every day. Using this you can work out how many orders to place for new stock and how much money should be distributed to your stores and suppliers. Now imagine your data protection officer says you can only see data related to customers who have loyalty cards. It will be impossible to pay your stores the correct amount or to keep the shelves stocked with what your customers want. The consequences will be catastrophic for the business.

This is an extremely simple analogy but it captures the essence of why partial data is a problem.

Central bodies in the NHS do a whole range of things that require complete datasets. How do you plan local services when your data about who uses them is incomplete? How do you understand where a service could be improved when the data might omit the details of the services most frequent users? How do you pay hospitals when you don't know how much activity they did? How do you work out the correct prices for that activity when the information about a significant chunk of the costs is missing?

What is disturbing is that the desire to remove data contradicts one of the goals of the patient opt-out. The original promise was that any opt out would not affect the care given to patients. This promise can't be kept if the people planning the service can't see all the data.

Without complete data, paying hospitals for what they do could be problematic for two different reasons. Hospitals are paid standard prices for most of their activity (for example, a standard cataract removal is £704 on the current tariff). The NHS has to know how many operations have happend to pay the hospitals the right amount. But it also has to calculate what that price is by a sophisticated process that maps all the costs associated with an operation onto the number of operations that a hospital does. Obviously, if the prices are wrong hospitals won't be able to cover their costs with the money they are paid. The prices are currently recalculated every year so the effect of errors in the price calculation won't show up immediately. But calculating prices with incomplete data can lead to potentially major errors.

Given that omitting data for some patients from the system that pays hospitals after january would be immediately apocalyptic for hospital finances, I presume that there will be some exemption. But, if there is, then the supposed protection of the data of patients expressing an opt out will be undermined. We can't even be sure what will happen as none of the people who know how the payment system and price calculations work have even been consulted on the effects of removing some data from their data sources.

What should be done

In a world where the people writing policy knew what they were talking about this is what would happen.

The HSCIC would fulfill its ICO obligations by restricting the data provided to non-NHS bodies. So medical researchers and drug companies would only get the data about patients who have not expressed an objection to data sharing. The HSCIC would send a strong message that it was enforcing patients' decisions about sharing their data. NHS bodies would continue to get complete data at least until a clearer definition of a type 2 objection has been formulated. This should be clear enough that doctors and patients understand exactly who can and can't have their data and, if the rules are set so the NHS can't use the data internally, the patients understand the significant implications for their care of not sharing their data.

Then we should identify everyone involved in setting this apocalyptically dumb policy and either sack them or move them to jobs where they can't do any more damage.

NHS capital to revenue transfers make things look better but reinforce the underlying problems

The NHS has found a way to make the ongoing deficits in trusts seem less awful. But looking less bad isn’t the same as fixing the problem and what is happening now reinforces the worst failures of the NHS. Here is why.

Deficits in NHS hospitals this year have already reached £1.6 billion which is the worst they have been for a very long time. This is clearly worrying.

The leadership has decided to take decisive action. The HSJ reports a comment from Paul Briddock of the Healthcare Finance Management Association:

“It seems that both Monitor and the TDA are trying to work locally with FTs and trusts to make capital to revenue transfers. They are asking trusts to consider scaling back their capital expenditure plans, releasing the cash that was previously going to be spent here to support the cash shortfalls being driven by their income and expenditure deficits.”

In other words the decisive response from DH, the TDA and Monitor is to fiddle the accounts to make things look better and damn the effect on making the long term much worse.

This is a major worry as the “fix” reinforces one of the worst habits the NHS exhibits when spending money. The system is far too focussed on the short term and neglects the allocation of money to the things that would lead to long term, sustained improvement in operational productivity and quality. Here is an analogy:

You run a factory that makes widgets. Your factory has a dodgy leaky gas supply and old electrical wiring which sparks a lot. Fires are common, cause lots of damage and cost a lot to put out. And, obviously, fires cause factory closures and get in the way of your ability to make more widgets. You can’t currently make enough widgets to meet the demand, which is insatiable.

Your budget is under pressure. Perhaps the source of the problem is that, although widget making looks profitable, this assumes the factory doesn’t break down or incurr extra costs like paying firefighters.

The board of your firm decides that the response is to cancel the capital programme of fixing the gas leaks and rewiring the building. So you can have enough cash this year to pay the firefighters when they come to fix the increasing number of fires. And you can still show a surplus even when the factory keeps breaking down.

Exactly when do you realize this is perpetual madness? But it is (however imperfect the analogy) exactly what the NHS is doing. And has done in the past even when there was plenty of money sloshing around the system.

The NHS could be improved in big increments by careful spending on the right things. Buildings could be better designed to support staff and current treatment processes (there are still many pre-NHS facilities). Better equipment could deliver cheaper, more reliable diagnoses and treatments. Most importantly (and most neglected) better information systems could provide the information required for the multiple staff who interact with patients to deliver coordinated care (the organisation-focussed idea of integrated care is faintly ludicrous as most single NHS organisations can’t coordinate the care inside their own walls because their systems for managing patient information are so poor). Most hospitals don’t have reliable information to tell them whether alternative ways of organising their care yields better efficiency or quality.

Many of those improvements depend on capital spending, which has been neglected in the past and is being postponed now to make a superficial choice between making things look good rather than actually making them good. The NHS can't improve unless it spends on the long term things that enable that improvement. That's what capital spending should be about.

This problem is greatly exacerbated by the NHS’s general suspicion of management. Managers are often thought of as either useless bureaucrats or actively harmful parasites. And the desire of politicians to seek attractive headlines rather than effective action reinforces the problem (as I’ve argued here). The reality is that the NHS is so undermanaged that, some commentators put it (quoted on the flipchartfairytales blog), if it were a charity:

“Our own position is that we wouldn’t want to support an organisation spending less than 5% of its total expenditure on good management. Without this we would lack confidence that the objectives of the organisation would be achieved.”

The NHS spends something like 30% of that metric.

It doesn’t fill me full of confidence that the latest plans of the leadership of the NHS are focussing on making the superficial accounts look better rather than making a case for the capital spending on long term improvement and the management capacity to identify the key requirements and ensure the spending delivers the improvements.

I’d rather see the NHS facing a major short term crisis than see it reinforce the worst habits that have led to its current position.

It's not the doctors: it's the beds...

People admitted to hospital are more likely to die if the admission happens at the weekend. The government thinks this is because hospitals don't really work 7-days a week. So they are engaged in an attempt to rewrite doctors contracts so they can't opt-out of weekend work. This is the wrong focus.

People don't stop getting sick at the weekend. So hospitals really shouldn't provide a worse service then. But the evidence suggests they do (though it should be admitted that working out the weekend mortality is both hard and controversial). The government thinks this is because consultants can opt-out of weekend working (though how many actually do this is unclear and a subject of significant controversy).

While it is obvious in activity statistics that hospitals function very differently at the weekend, it is a lot less obvious that the doctors are to blame. And focusing on them may be a mistake. A recent study (reported in the BMJ here) casts some new light on the problem that suggests the focus of government policy may be wrong.

The study reported a clear reduction in mortality in a hospital when bed occupancy was reduced. The text below is a version of what I said in a BMJ rapid response and on LinkedIn when I first saw the study.

I'm puzzled that more commentary has not noted the relationship between this study and the current topic of weekend mortality in NHS hospitals.

The government has focussed on trying to force changes to medical contracts to eliminate the ability for doctors to opt-out of weekend work in the hope that this will fix the problem of excess mortality at weekends. But, by focussing on the doctors, they miss the more general point that just having more doctors won't fix broken operational processes at the weekend. This study points to a much broader problem that links mortality to those processes.

The missing link is the fact that the processes for discharging patients and therefore keeping bed occupancy down are widely broken at the weekend. While admissions are lower as few elective patients are admitted, discharges are muchlower. Emergencies, of course, continue to arrive. So the beds fill up as the overall process for discharging patients is usually dysfunctional at the weekend. This leads to very clear patterns (easily observable in activity statistics and for length of stay). In many hospitals beds fill up at the weekend.

The presence of doctors at the weekend isn't (or shouldn't be) the critical factor here. Most of the discharges that should happen are probably routine and could happen automatically without medical supervision. But they often don't because the process for discharge has been poorly designed (this is sometimes because it has an unnecessary requirement for consultant sign off).

We have known for some time that the dysfunctionality of processes associated with the flow through beds is the dominant cause of delays in A&E (which are bad for patients). And we know that A&E delays are bad for mortality and outcomes. Monitor's recent report adds further weight to this hypothesis. This study now reports a direct link to mortality when beds are crowded.

The high bed occupancy is directly bad for patients and is caused by poor operational management of discharge processes. Those processes are much poorer at weekends than they are during the week. This alone may explain the weekend mortality effect.

The weekend mortality problem is not primarily a medical problem, it is a management problem. The lesson for policy is that a focus on medical contracts is a distraction. If we really want to fix weekend mortality we should focus on improving the way hospitals manage the flow through their beds, especially at weekends. As a bonus, this would also lead to major improvements in hospitals' ability to treat patients quickly in A&E. This should be a double win for patient outcomes.

NHS is running out of money, again

NHS hospital finances are in deep deficit (again). But a lack of money isn't the primary problem. While more money is probably needed, the system will still be in trouble if it doesn't address the deep underlying problems it suffers from.

[Note: this is an extended version of a comment I made in response to Alastair McClellan's HSJ editorial on the current financial state of the NHS.]

Over history, the NHS is used to solving every problem with more money but it has little experience with redesigning the way it works to cope with less money. or to do a better job with the same money. Over its life it has, on average, had a budget that increases significantly faster than the economy as a whole. During the Blair years its budget doubled in real terms in less than a decade.

The NHS needs to do better both in quality and efficiency. But every time budgets are tight, the wrong things get cut and the problems get blamed on the budget cuts not the chronic failures to modernise operational practice. 

The trouble is the sort of investments that might lead to significant operational improvements are neither sexy nor popular.

Much more IT, for example, could lead to the automation of data collection and administration, freeing medics from tedious admin and form filling and thereby leading to better decision making when they treat. Much more usable IT could reduce the burden of fragmented and user-hostile current systems again freeing up useful time for the benefit of patients.

Better management quality especially at the operational level might lead to better performance and a better workplace for nurses and doctors (better matching of capacity and demand is good for patients and better roster design is good for staff). But the naive slogan "more staff to the front line" make better newspaper headlines than better management of the staff on the front line (see my comments here).

Better understanding of costing could lead to improved focus for improvement efforts (if you don't know where the money goes–and many trusts don't according to costing audits–how can you know what needs to improve?) Or how come so many trusts argue they are not being paid enough to operate a service when they have such a poor grasp of how much that service costs?

Sadly none of the key things that are obviously broken in the NHS are things that generate good newspaper headlines for politicians who choose to invest in fixing them. And the internal lobby that calls for more staff and more money to solve the current problems don't have the wit to grasp that more staff in a badly managed system doesn't improve things much.

It is far too tempting, for example, to cut the capital budget for short term gain and far too headline-pleasing to focus on front-line staff numbers than on improving the way staff are organised. 

It is also too tempting to focus on big top-down structural changes rather than the much more effective bottom-up operational changes that actually drive long term improvement (see my comments here).

So the response to a short term crisis makes the long term problems underlying that crisis worse. And the medical lobby that argues that more money fixes everything reinforces the underlying problem by offering a naive analysis of what the problem is.

So, even if the NHS gets a short term injection of money, it will likely be spent on the wrong stuff.

The NHS probably does need a significant injection of cash. But it needs a serious dose of sense about bottom-up productivity and quality improvement even more and we shouldn't let the current debate distract from that.

Good Strategy, Bad Strategy, NHS strategy

Strategizing and planning takes up a humongous amount of management effort in the NHS. Given the quality of what emerges, that is mostly a waste of effort.

There are a lot of business books about strategy. But not many good books about strategy. In fact I’d go so far as to say there may only have been five of any merit in the last 30 years. The most recent in my short list was by Richard Rumelt and is called Good Strategy, Bad Strategy.

Rumelt thinks most strategy is bad and provides a useful diagnostic to help identify it. And he thinks that good strategy has of a kernel consisting of just three things: diagnosis; policy and plan. while his focus is mostly on business strategy the issues apply in the public sector too and I want to look at some examples from the world of the NHS. Not necessarily positively.

But first let’s look at a distilled version of what he says good strategy should be and how to identify when it isn’t. And then I’ll review some NHS strategy stuff against the standards (hint: I won’t be very positive).

He argues that bad strategy tends to dominate:

“Unfortunately, good strategy is the exception, not the rule. And the problem is growing. More and more organizational leaders say they have a strategy, but they do not. Instead, they espouse what I call bad strategy. Bad strategy tends to skip over pesky details such as problems. It ignores the power of choice and focus, trying instead to accommodate a multitude of conflicting demands and interests. Like a quarterback whose only advice to teammates is “Let’s win,” bad strategy covers up its failure to guide by embracing the language of broad goals, ambition, vision, and values. Each of these elements is, of course, an important part of human life. But, by themselves, they are not substitutes for the hard work of strategy.”

If you are starting to feel uncomfortable about your organisations strategy, then welcome to the club.

So what does a good strategy consist of?

“The kernel of a strategy contains three elements: 1. A diagnosis that defines or explains the nature of the challenge. A good diagnosis simplifies the often overwhelming complexity of reality by identifying certain aspects of the situation as critical. 2. A guiding policy for dealing with the challenge. This is an overall approach chosen to cope with or overcome the obstacles identified in the diagnosis. 3. A set of coherent actions that are designed to carry out the guiding policy. These are steps that are coordinated with one another to work together in accomplishing the guiding policy.”

What I like about this definition is its clarity. In a few sentences it cuts to the heart of what is wrong with a great deal of the sloppy thinking that many organisations call “strategy”. He elaborates a little more:

“The core of strategy work is always the same: discovering the critical factors in a situation and designing a way of coordinating and focusing actions to deal with those factors…

...A good strategy does more than urge us forward toward a goal or vision. A good strategy honestly acknowledges the challenges being faced and provides an approach to overcoming them…

...good strategy includes a set of coherent actions. They are not “implementation” details; they are the punch in the strategy. A strategy that fails to define a variety of plausible and feasible immediate actions is missing a critical component…”

To summarise in my words a good strategy needs the following:

• A diagnosis of the most critical problem being faced by the organisation
• A policy to deal with the most critical problems that also acts as guide to rule out actions that will distract from dealing with the most critical problem
• A realistic, achievable plan of things that can actually be done that deal with the challenge in a way that is consistent with the policy

That doesn’t seem to hard, does it? Apparently, though, it is (and not just for the public sector) as few organisations come close to having strategies that meet those criteria. To be fair it isn’t defining good strategy that is hard, it is generating good strategy which nobody finds easy.

So how do strategies in the NHS stack up?

Here is an example of one way things fail.

Last winter NHS England was keen to encourage CCGs to sort out their perpetual winter crisis. They were happy to spend serious money (I believe more than £500m has been spent in the last two years) on avoiding the bad headlines that come around every year as “winter pressures” appear to overwhelm the emergency care system. I got a phone call from one CCG who had been kicked out of the room for producing an unconvincing recovery plan (I am an expert on emergency care performance having worked on and off in the area since the 4hr A&E target was originally set). I won’t name them to protect the guilty.

I have my own views on what the problem is in emergency care and I’m one of the few people to have produced analysis of the performance data that tries to narrow down where the problem is (the regulator Monitor have recently done an exhaustive analysis that pretty much agrees with my less complete analysis and experience).

So I asked the CCG to tell me about the plan they had presented. I compared it against my list of things I thought were likely to work. There was no overlap. I won’t go into the detail but the key issue was that most actions were focussed on diverting patients from A&E on the assumption that the problem was that the emergency departments were being overwhelmed by demand. This should be one of the easiest hypotheses to refute as the weekly national performance data have never shown any relationship between the attendance volume and performance (You can find some of my analysis of this elsewhere on this blog. Monitor’s assessment agrees with mine.)

So I quizzed the CCG as to why they were focussing on actions that didn’t work and proposed that they should look at some other ideas (for example whether their hospitals had a problem with discharging patients and finding free beds. This is Monitor’s top identified cause of poor A&E performance and the one I’ve been ranting about for years). I suggested some tools (eg this one) they could use to explore whether this issue was significant locally. I assumed they had never thought of this. I was wrong. They had already done this analysis and identified that beds were a serious problem in local providers but had ignored that in their strategy. Why? Because, they said, they didn’t want to annoy the clinicians in the hospitals as they didn’t agree with the analysis (even though it was based on their data).

So they produced a strategy that had essentially no hope of addressing the problem they had. They chose to address headlines and naive explanations about what the problem was rather than face down local political pressures that were driven by denial about the real source of their problem.

This identifies two issues that recur repeatedly in the NHS and lead to much “strategy” being built on a foundation of air.

• They fail to identify the critical issue in the situation
• They fail to choose a focus that might upset a strong constituency and prefer multiple actions that make people feel something is being done

Of course, the second factor is often the cause of the first. Even when we know what the problem is we can't address it because of politics.

These failures are pervasive in public sector strategy. Even when one part of the process is done well other pressures undermine the result. In the NHS we sometimes (though far too infrequently) see some decent diagnosis of what the top problem is. But the strategy becomes muddled because of an inability to choose to focus on just the top problem. More frequently, the strategy addresses political issues and never bothers with the objective analysis of what the challenges actually are. This problem is exacerbated because just about every distinct group inside the NHS has some lobby pursuing their interests.

The RCGP (the lobby for GPs) thinks the key problem for the whole NHS is that the government hasn’t done enough to mitigate demand on them and hasn’t recruited enough new GPs to make the workload bearable. They even produce numbers to back these ideas up. But the numbers are bogus as the NHS doesn’t collect reliable data about how many GP appointment there are. Moreover there is significant evidence that GPs who apply some operational insights to how they book and deal with appointments can reduce their workload substantially while improving patient satisfaction. The correct diagnosis of the problem might be a poorly designed and inflexible appointment process and not a tsunami of demand.

Or, in recognition of the NHS’s inability to operate properly at weekends, Jeremy Hunt demands changes to doctors contracts. Nobody seems to have done any analysis of the real problem.  Why bother when the headline solution seems to be so attractive. But, while it is clear the NHS doesn’t operate well at weekends, it is far from obvious that the fault is driven by lack of medical cover. Piss poor processes for managing discharges from beds seems to me far more likely, and that isn’t fixed by having more doctors around.

And there are big areas of NHS strategy where we could apply those criticisms. Especially where anything involving those newfangled things, computers. The National Information Board (NIB) has a framework for the future of NHS IT (which is describes as a framework, wisely since it isn’t much of a strategy by Rumelt’s definition). The NIB framework says a lot of plausible things about what the NHS should do with computers and IT. But it lacks a compelling diagnosis of what is broken or why the NHS hasn’t done obviously beneficial things in the past. And it flunks the second test as well by failing to choose. It defines a wide range of actions rather than focussing on the most important action. In an attempt to please many, it fails to make a compelling case to drive a focus on anything that might make a difference.

And many of the other strategies in the NHS suffer exactly the same problem.

A hospital is in trouble. Let’s have a merger! We should get some economies of scale at least. We have compelling evidence this strategy doesn’t work. And one of the key reasons is that scale isn’t usually the problem and mergers distract from rather than fixing the underlying operational problems that cause the trouble in the first place.

Emergency performance is poor in the region. Let’s have a major service reconfiguration! Again, these rarely work as the diagnosis is wrong at the start. Scale isn’t usually the problem and scale doesn’t lead to better operational performance not least because larger units are harder to organise than smaller units.

Demand is growing faster than we can cope. Let’s pursue integration of social care, primary care and secondary care! I’m not even sure what the logic for this is. We know that few NHS organisations are any good at internal coordination among their departments even before we bring others into the mix. And if coordination is what we need we don’t need organisational integration to achieve it. Coordination is an information problem not an organisation structure problem. The drive for integration is not based on a coherent diagnosis or a coherent policy approach. It is pure wishful thinking based on a goal we’d like to pursue which it isn't even clear would make any difference to the underlying problem.

Even when good ideas emerge in the NHS they are often undermined because the other essential elements of effective strategy are missing. The recent saga of Cambridge University Hospitals is an example. I’ve written in more detail about this here. The now departed boss had a reasonably plausible vision for where he wanted the hospital to go and it was based on a reasonable diagnosis of a key organisational problem: the lack of good quality information about patients and hospital activity. His visionary solution: a new hospital-wide eHospital system from respected supplier Epic. Nothing wrong with that. But compelling vision is merely a wish fulfillment fantasy in the absence of the other elements of an effective strategy. It seems like his strategy lacked both focus and the hard, detailed operational plan that would turn it into reality. As a result he has departed and the hospital is in a deep, deep hole.

I could go on, but I’m not sure it would help.

Given the humongous amount of time and effort the NHS devotes to planning and strategizing you might hope that the system would do a better job. For those of you who have to contribute to this futility, save yourself some effort by reading Rumelt’s book. Make sure your strategy has a kernel that works: a diagnosis, a focus and a plan. If it doesn’t, then don’t even bother writing it down or printing it. In fact, run for the hills: you are on the road to nowhere.

Government policy on the NHS gets all the attention but it isn't what matters most

When debating how to improve the NHS most of the focus is top-down government policy. It's either the magic solution or the source of all evil, depending on which side of the debate you are on. Both sides are misguided: it's incremental, bottom-up operational improvement that matters most.

I'm going to make an argument about the NHS that will annoy almost everyone from the diehards in the NHS Action Party to the neoliberal blowhards who would put every NHS activity into the private sector. I'm going to argue that the entire debate they are having is irrelevant. It is a complete waste of effort, thinking and newsprint (or electrons, for the younger generation who consume everything digitally).

The debate, whichever side you are on, starts with the assumption that top-down policy is what matters for driving improvement in the effectiveness, efficiency and quality of care. One side argues that things are a mess because of the purchaser provider split and the intersection of competition and austerity. The other argues that the problem is a failure to introduce more competition, more incentives for efficiency and quality and more mechanisms to allow the market to sort things out. And then there are those who argue that the whole framework of NHS regulation is a plot against professional standards of medics and they would do a better job if left to their own devices.

I've taken sides in some of these debates. For example, I'm relatively in favour of provider competition (on quality not price and not in imitation of the corrupt american model where the "market" seems to be rigged in favour of big business to the severe detriment of patients). But the evidence about competition in England (it does exist, see this skeptical review in the BMJ) while it exists, doesn't suggest the effect is large. Also the more integrated NHS systems in Wales, Scotland and Northern Ireland have not demonstrated better long term performance than the system in England in clear contradiction of the idea that the market consumes 14% of the English NHS budget for no good purpose. (The frequently quoted 14% is complete nonsense, by the way, as the rapid responses to this BMJ article which is one of the first to mention the estimate should make clear).

Despite my preference for some provider competition, what the evidence says most clearly is that it doesn't seem to matter much. This argument cuts both ways: the evidence (supplemented by the comparison across the different models of NHS structure in UK provinces) suggests that there are no gains from abolishing it either (unless you count having a system that corresponds to your personal ideology as a source of improvement in your general mental health). The one thing everyone seems to agree on is that major top-down changes to the NHS structure are costly and disruptive in the short term. So, if you are one of the many who think we should abolish the commissioner-provider split, you are going to need much better evidence about the gains to justify the short term cost.

The irrelevance of the top down structure of how the NHS is organised is just one clue that suggests that all those top-down policy arguments are irrelevant. Another is the failure of hospital mergers. The planners in the Department of Health, like central planners everywhere, work with what they know. And what they know is that, in theory, there should be economies of scale. Bigger hospitals should have lower costs than smaller hospitals. The same thinking drives service reconfiguration: bigger A&Es should be easier to manage and cheaper to run than smaller A&Es. But what planners know is only a fraction of the truth. In reality most mergers fail to achieve their goals (see the Kings Fund blog and report on mergers). As far as I can tell this also applies to most major service reconfigurations (there are exceptions for some low volume specialist services such as Stroke and Major Trauma).

Two other clues bolster my hypothesis. One is that the only a small proportion of the cost differences among hospitals seems to relate to size.  Another is that the staffing complement of A&E departments explains essentially none of the variation in performance (this research was done in the mid 2000s and I wrote about it in the BMJ; I think it still holds true). Both point to the idea that management matters more than the scale or resource levels (which is what get the attention because they are easier to observe).

The simple idea I want to propose is that all those top-down strategies can, at best, only make minor improvements to the NHS. It seems obvious that, when we need big improvements to bridge
the £25bn productivity gap, we should aim for big changes in how the system works. But that's not what the evidence says. In reality, top down change has about the same expected success rate as a
paraplegic contestant in an able-bodied arse kicking contest.

Large, sustainable change more often arises from a system that knows how to accumulate many small, achievable changes. This BBC article describes the idea using the way it led to dramatic improvement in Britain's cycling team performance. The article also notes how big the improvements can be in healthcare. Describing the experience of Seattle's Virginia Mason hospital:

But this was just the start. They started to use checklists in the operating theatre, to alter the ergonomic design of surgical equipment, to systematically improve clinical hygiene. Each improvement seemed small, but they rapidly accumulated.

What happened? Since the new approach was taken, Virginia Mason has overseen an astonishing 74% reduction in liability insurance premiums. It is now regarded as one of the safest hospitals in the world. That is the power of marginal gains.

My point is that effective change comes from the accumulation of small operational improvements in how things are managed on the shop floor. These probably account for 80-90% of all effective improvement (we can let well-designed top-down policy and structural changes have the remainder.)

If I'm right the entire debate about NHS policy is irrelevant. In fact many critics of government policy actively distract attention away from the real sources of improvement by assuming that only more resources can improve anything or only reversing [insert whatever government policy you don't like here] can lead to improvement.

The whole debate needs a new perspective. We need to look for improvement from the bottom-up not top-down. Small marginal changes to operational processes can lead to large sustainable gains in quality and efficiency. And that is what the NHS desperately needs.