Tuesday, 29 September 2015

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.


  1. This seems very plausible to me. I would be interested to know to what extent you think it implies that subsidiarity is a wise course for management. I suppose that one of the challenges is to recognise and preserve local improvements when they have occurred and find a way for them to spread without having them imposed elsewhere by a top-down management initiative.

  2. I agree that subsidiarity is the right way to go. Currently the system seems to exhaust all its (already limited) management capacity in a sort of Stalinist top-down control where the centre tries to control how things get done in detail. A system where local operational management could innovate and where those improvements could spread rapidly would be a lot better.