Friday, 24 February 2017

There are no magic bullets to cure the NHS. But better diagnosis of its problems and clearer focus on addressing their root causes are a good place to start.

There are a lot of symptoms the NHS is failing. But plans that address the symptoms are not going to fix the root causes of the problems. And a dilution of effort across too many improvement projects will yield little improvement. Accurate diagnosis and ruthless focus on tackling root causes rather than symptoms are essential.

The government knows the NHS has a problem but is confident that current plans can fix it. Campaigners disagree. To some this is a government conspiracy to underfund the systems as a prelude to privatisation; to many of the less conspiracy-minded  the primary problem is just underfunding. But those are not the only things said to be a major cause of the current crisis: not enough GPs, A&E doctors, beds, social care places. Too many patients, old people, worried well patients have also been suggested.

The NHS has a lot of very challenging problems. This, you might think, would be a strong case for very careful focus so the scarce resources available are not diluted so no problem gets enough attention to address it.

When organisations face complicated problem one of the secrets to successfully resolving them is focus. No organisation has enough people, skills or money to tackle every problem and attempting to address too many at once tends to ensure that every effort is so diluted none will succeed. This is an acute problem in the NHS which is very short of people with good problem solving skills and the money required to invest in improvements.

But the only focussed strategies for solving the NHS crisis come from campaigners and lobby groups and they have the disadvantage of being about as credible as a one legged man at an arse kicking contest.

In fact the magic bullets suggested by campaigners get in the way of effective action as they all claim to be the only significant thing that needs to be done, a claim that lacks credibility because it depends more on what they are lobbying for than on any actual analysis of the problem.

Inside the NHS the problem isn't any better. One hospital where I have been working was put into special measures after a bad CQC report. The report is problematic to start with as it is a long list of hundreds of symptoms that things are broken and dysfunctional. The hospital's response is worse: a list of nearly 100 projects designed to address the top symptoms raised by the CQC.

This programme of work is a serious problem itself. The hospital has so little management capacity that tackling just a handful of major projects would be a stretch. And, when the individual projects conflict with each other there is no overriding rationale for deciding which one gets priority.

There is an alternative that would help both this hospital and the NHS as a whole. The alternative is to focus on the handful of underlying problems rather than the scores of symptoms. But this involves developing an understanding of how the whole system fits together and doing the analysis to identify the causes of problems and not just their symptoms. This is both hard and rarely done.

But let's try anyway.

More than half the NHS budget is spent by acute hospitals. And there are many symptoms of failure manifest in current hospital performance. Most are running deficits; many have recently seen the worst A&E performance in decades; elective waiting lists are growing with many breaching the key waiting time targets; many face serious recruitment and staffing problems.

A&E performance attracts many of the headlines. The problem is often blamed on the relentless increase in demand. Hence 15 years of money spent trying to reduce that demand by investing in primary care or in diverting patients to other services. All of which has had no measurable impact on the levels of demand or the performance of the system. Current STPs continue this grand tradition of failure like an unlucky gambler who assumes his next hand will be a winning one. Others blame the problem on a lack of A&E medics or nurses. But staffing has increased faster than demand over the last decade and performance has continued to decline. Yet others blame the many patients who arrive at A&E but could have been treated elsewhere. More focussed analysis notices that this group isn't the one with long waits (that would be patients sick enough to need a bed) or that this group can be treated quickly and cheaply as long as the A&E organises itself effectively to do so (some have put GPs at the front door doing the quick, cheap and simple things that would have happened had they gone to a GP. This is often characterised as "diverting" patients from A&E even though it is actually just organising the work inside the A&E to better match the needs of the patients who arrive).

There is a diagnosis that explains the majority of the observed symptoms in A&E that has the advantage of also explaining problems with waiting lists. It even suggests that many of the other symptoms of acute failure may have the same root cause. The diagnosis is that most hospitals don't organise the flow of patients through their beds in an effective way. When flow is blocked, capacity to treat electives is lower, hitting the waiting list targets and the trust income. Bed occupancy is too high, lowering flexibility, increasing stress on staff, potentially damaging infection control and certainly causing knock-on delays in A&E admissions. When A&E is stuffed with patients waiting for a bed, its flow becomes problematic for even minor injuries leading to a crowded department with a lower capacity to treat patients. And one with a higher workload for staff and a more stressful environment. And, consequently, higher staff turnover and recruitment problems.

In fact problems with beds tie together an incredible number of other symptoms that a hospital is failing. But the problem with flow is rarely addressed as a core problem at all. Instead the symptoms are tackled in a siloed and incoherent way which wastes resources and dissipates motivation when the individual initiatives fail. And the programmes to tackle the symptoms conflict with each other further reducing their chances of success. This is inevitable when there is no coherent vision of the central root cause of the observed symptoms. Which is unfortunate because that is what most NHS plans at every level from STPs to hospital improvement plans look like.

It is not uncommon to have an improvement programme that contains separate projects to deal with A&E recruitment of nurses, A&E recruitment of consultants, staff retention, diverting patients to other services, improving compliance with agreed professional standards, reducing medical outliers in surgical beds and vice versa … all of which would be smaller problems if only the central underlying problem of poor flow were addressed.

Neither individual hospitals nor the small staffs developing STPs have much management capacity to start with. The only way any project will make progress is to focus the available effort on just a handful of goals. And it would help if the goals were based on a very solid understanding of the root causes of the symptoms and not just the symptoms themselves. It is quite possible to devote a great deal of effort, for example, into diverting patients away from A&E (certainly many have tried in the last handful of years) but but this has not worked and wouldn't impact performance even if it did. Wasting resources on doomed wishes is just plain stupid and counterproductive.

If the NHS wants to improve it needs to get better at both diagnosing the root causes of its problems and better at marshalling its resources to focus on those underlying issues. Nothing else matters more.


  1. Thanks, interesting blog. But aren't STPs specifically there to do what you suggest? ie "focus the available effort on just a handful of goals"? or am I miss reading them?

    1. Unfortunately, there is a big difference between what STPs are supposed to do and what they are actually doing.

      For example, too many are planning to divert patients from A&E services. This is based on the false diagnosis that the problem is too much demand. It also assumes that we know how to divert patients to other services (we don't) and that fewer utterances will improve performance (it won't). The real problem is that the emergency care system isn't designed to adapt to the demand it faces and that hospitals don't coordinate the flows through their beds to match the demand.

      And most STPs seem to be trying to do too much. This is because they are tackling symptoms (of which there are many) and not the underlying diseases (of which there are few).