Do hospitals need to close?

Prof Paul Corrigan, a former advisor to Tony Blair has argued that, unless radical action is taken the NHS will need to find £5bn to bail out failing hospitals.  Some hospitals will, therefore, need to close, but its OK because the model of care that replaces it will be better.  It's not the first commentary on this topic, with Lord Crisp being the most recent high profile commentator to argue this.

It is hard to disagree with some of the conclusions, given what I have seen to date having applied the Vanguard Method in health.  What concerns me though is that the logic that is driving these conclusions is one of managing cost and not managing value.  Unfortunately, the reality is that if you manage costs, your costs go up.  What leaders who apply the Vanguard Method understand is that cost is in flow - manage value, end-to-end, from a users perspective, and your costs will go down.

There is plenty of evidence to support this, perhaps the most obvious one being walk-in centres.  Everyone had to have one of these, millions were pumped into building them on the basis that they would take care of the "ambulatory care sensitive" cases, A&E attendances/admissions would go down and everyone's a winner.  Patients get care closer to home.  Commissioners save money.  Trusts create capacity.  Only trouble is that they proved to be so popular they became unaffordable, particularly as there seemed to be little or no impact on what was coming through the front door of the hospital. Overall costs went up.  Managing costs had the opposite effect to that intended.  

Better would have been to design a system to respond to people in the right way when they put their hand up for help based on knowledge and understanding, not create another service solution based on instinct or convention.  Fortunately, when PCTs started closing them, the managers in charge could at least pat themselves on the back for having made a significant contribution to their efficiency savings....

If it is true that hospitals will need to close, better to make decisions like that from a value, not cost point of view.  By doing so we will be sure to be cutting that which ought to be, not that which can be.  We are then in a position to build our business models based on knowledge not convention.

The concept of "solution factories" again sounds plausible, but right now, fills me with dread.  If centres of excellence are not determined from a value point of view then this could be another example of blindly plumping for a model based on an assumed economy of scale.

I worry that decision makers will opt for approaches like this without first understanding what perfect looks like from a users perspective.  The risk is they apply current convention and logics of cost and activity as the basis for change.  If that happens then as plausible as Prof Corrigan's analysis might be, it is almost certain that the wrong decisions will be made, with the system ending up paying more, not less for the new model.

Paradigm shift

A quick scan of the literature over the last 18 months underlines the acknowledgement by the system that we need to do things differently.  In fact, a look back across the history of the NHS shows that there is a repeated recognition that we haven't got things right.  You would hope that such a conclusion would be reached given the amount of change it has been subjected to.  Otherwise all reforms would have been pointless, right?

Every day the NHS and the people who work in it do incredible, life changing things that are rightly admired.  But, either because of personal experience, or because of the stories that we hear so regularly in the press, or because our leaders tell us things are not right - be they former CEO's admitting that the NHS built too many hospitals or our political leaders who tell us that the NHS is not responsive enough and not getting the same outcomes as other comparable nations - or the colossal waste that is PFI, or the strange but true stories of Independent Sector Treatment Centres paid tariff plus for work they didn't do.  Or NPfIT.  Whatever it is there remains a sense that perhaps we haven't got it quite right.  In this context, quite why, in his recent critique, Gerry Robinson felt that the one thing that was missing from the reforms was a central planning function baffled me.

So we talk of the need for paradigm shifts and invest time in supporting people to be able to successfully lead health economies through this difficult time.  But despite all the events that one attends talking about how the Fosbury flop was a completely different paradigm from what went before; or how blue tits were able to adapt to the change to foil tops on milk bottles and still take the lids off to get to the cream whereas robins couldn't, the breakthrough hasn't quite happened.

Why is this?  I believe that it is because what is missing is a method for looking at how we "do"change.  We continue to believe that the answers lie in competition and incentives, targets and performance indicators, M&A and economies of scale, lean and six sigma without understanding what it is that people want and need when they put their hand up for help.  We then end up being seduced by ideas for "betterment" that we import or apply (e.g. Healthcare Maintenance Organisations, competition, choice etc) without first taking the time to understand.

One could be forgiven for concluding that this is the result of lazy thinking.  In the rush for change the desire for a "go to" answer becomes overwhelmingly compelling.  Or maybe its because we have become so used to commoditising our relationship as citizens with public services that all change is framed from the perspective of costs and activity, rendering us incapable of conceiving of change from any paradigm other than the current convention.

Whatever the reason, significant, radical, transformational change will not happen unless we are able to change the way we think about the problems we think we have and the methods we have to solve them.

Can the transformational change be as elegantly simple as I have described - focus on people and be clear about the purpose of what we do from their perspective; agree the measures that tell us that we have delivered that purpose and then, and only then, decide the method by which we systematically and sustainably deliver purpose?  Judging by the results of my experiments, I think so.  It is still early days, and as I have said before, I am still learning but the signs are very promising.  As I learn more I will share the results.  But what is clear is that current convention is a poor method for change.

Putting the "P" back into the NHS

David Nicholson wants the "N" put back in the NHS.  For those of you who have been thinking the last 6 months or so has been about people taking the "P" out of the NHS, I thought it would be nice to think about putting it back in again.  The "P" in question?  People.  What I see when I apply the Vanguard Method in health are local health economies and an NHS (in England) that are systemically incapable of understanding people.

A bit trite to say?  What if I told you that of a cohort of people that formed part of an experiment to find different ways of doing things, not one of them had been appropriately understood.  Because we then understood them, not one of them went onto the pathway prescribed for them.  Because we dealt with their problem, their experience was transformed - either by having a better life or, in one case, having a good death.  Because we did this, admissions were avoided, lengths of stay reduced, discharge to residential/nursing homes didn't happen.  The chances of all the cohort being special and not common cause? One in a million.

Here's a challenge for you.  Ask yourself whether or not, if you put all the assessments that different professionals make about a person together, would that give you a view of the whole person and their problem to be solved.  If not, do you think there is a problem here?

We talk about putting patients at the centre of everything we do, but we are systemically incapable of doing it.  My experience in having applied the Vanguard Method in health is that far too much time is spent on pathways, targets, economies of scale and other management things considered to be the bread and butter of management.

And yet it focusses good people on doing the wrong things.  The problem was, for me, summed up by what Lord Crisp said yesterday.  He effectively admitted that billions of taxpayers money was spent doing the wrong things which now have to be undone - but at least you can get through your A&E in 4 hours....  It was a shocking admission in my view, but an inevitable consequence of not taking the time to understand people and the communities they live in.  Unless this changes there will continue to be "missed opportunities" and much more wasted money.

Management iatrogenisis

One of the biggest challenges facing health systems is that of understanding patient safety.  It is suggested that the equivalent of 30 Boeing 747’s crash every month in America, 6 in Britain and 2 in Australia as a result of preventable medical errors.  Estimates vary but the rate of error and adverse events is in the order of 10% of all admissions.  In about 2% of all cases major disability or death occurs.  It seems that a major reason for this is what is known as medical iatrogenisis, or harm induced by healthcare itself.  It’s because the harm happens one patient at a time that this is a hidden epidemic and there isn’t the outcry and immediate action to resolve.

For systems thinkers this is shocking stuff.  The statistics make grim reading: a 1:10 chance of being harmed during a hospital admission; a 1:50 chance of a system induced death or disability; a 3:10 chance of ultimately dying normally but with an untreated pathology.  If all these were completely independent it has been estimated that the risk of misadventure or under detection by health system act of omission or commission of some description is 92%.

The good news is that at least your local hospital you will get through A&E in four hours....

I was reminded of this idea of medically induced harm following the recent debate about the prescribing of statins.  


Perhaps there is a deeper problem at play though.  Maybe it's not medical iatrogenisis (as genuine an issue this may be) but management iatrogenisis that is the problem.  In other words, harm induced by the current management paradigm and its preoccupation with targets, budgets, economies of scale, standardisation, centralisation, organisational configurations and any number of management concepts that focus doctors, nurses and other staff on the wrong things.

What I see as I study health systems is that it is finance that drives behaviour, not purpose from a users perspective.  It is the management of risk that concerns people, not solving a persons problem.  It is the delivery of targets that are uppermost in people's minds not understanding the type and frequency of demand on a system and designing for perfect against that demand.

For systems thinkers understanding the purpose of the system from a users perspective is the critical issue.  If the purpose of the system is to cause preventable harm then we can all pat ourselves on the back and congratulate ourselves on a job well done.  Presumably that is not what you want for your system though?

The alternative?  Study your system and understand the types of demand you face.  How frequent and predictable is it?  Is it demand that is valuable from the users perspective - i.e. "I need help and you have solved my problem" or is it what we call failure demand - the failure to do something or do something right for someone?  Then look at all the reasons that get in the way of the system delivering what a person needs as and when  they need it.  If you have the same experience as I have had you may conclude that most of the initiatives designed to improve the system are having quite the opposite effect.


What to do once you have this knowledge?  Experiment.  Allow the patient to set the boundary of the system.  Make expertise available as and when required, not through complicated referral processes or eligibility criteria.  Become pathological in your quest to understand.  But understand people first, not processes.  That can follow.


There may be false starts, you may make mistakes.  But so long as that is part of a learning and adaptive process, with the right leadership and the right framework for change the system will end up in the right place.


In doing so you might find that, instead of spending time worrying about abstract notions like readmissions, you sort Terry's alcohol dependency issues out and avoid his repeat, episodic and transactional hospital visits.  By understanding Alfie's need for independence you think of replacing the buttons on his shirt with velcro so he can dress himself, not depend on someone coming into his home to offer assistance.  Rather than be concerned about eligibility criteria, you avoid the flightpath to dependence and expensive residential or nursing home placements by not putting Alice in hospital and labelling her confused and incontinent because she has been assessed out of her normal context and there has been no-one to answer her buzzer when she needs to go to the toilet.


Many of the conventions we simply take for granted, the split between primary and secondary care, the purchaser/provider split, the health and social care split then become redundant.  Artefacts of a world based on the notion that industrialising services was a good idea.

The harm we are causing is happening one person at a time - that doesn't make it any less shocking.  It is also happening one target at a time; one initiative at a time; one policy at a time.  And for all efforts that staff make in spite, not because, of the system; for all the reports, KPI's and balanced scorecards that say that there is no need for concern, everything is under control, don't be fooled.  The system is broken and our attempts to fix it using traditional management approaches is the cause, not the solution

Assessment vs Understanding

The most profound irony we uncover is that everyone in the system spends vast proportions of their time collating patient information and updating systems and yet the root cause of all the damage we do to people is that we know nothing about them

The quest for efficiency in the NHS - the answer?

I met Sir Muir Gray once.  I had heard about him before I met him and was impressed by what he had achieved.  Plus he was a "Sir" and I had never met one of those before.  It all made me a little star struck.  He asked me a very simple question - what has been the most influential management book you have read?  I must admit I fluffed my lines.  I meant to say, Maverick by Ricardo Semler, but for some strange reason I came out with The Unbearable Lightness of Being by Milan Kundera.  A great book, no doubt, but not quite what Sir Muir was expecting I am sure.  Of course that conversation happened before I read John Seddon's Freedom from Command and Control, a book I now consider required reading for any leader, particularly those that want to deliver excellence in public services.  Certainly it has made me realise that a lot of what is written, as plausible as it might sound, is not worth the paper its printed on.

I say met him.  It was more bumped into him.  I was reminded of my toe curling that subsequently occurred by a link that I received from the "Right Care" blog, something that Sir Muir has been instrumental in creating.  The link was to the Nuffield Trust and a presentation by Professor Alan Garber (Professor of Medicine at Stanford University) called "Competition, Integration and Incentives - The Quest for Efficiency in the NHS".


In a nutshell, according to Professor Garber, the challenge health care poses to the wealthy nations of the world, the overriding problem to be solved, is that there isn't enough money.  The answer, his prescription, is competition, integration and incentives.

Regular readers will know that I am still learning about the application of the Vanguard Method in health.  But from what I have seen and from what I know about other systems here, in a nutshell, is my view:

• The problem as described - maybe, but not based on what I have seen
• The answers prescribed - wrong, maybe, wrong

In fact, two of the three key components will definitely increase costs and one might, depending on what it means.  That might come as a surprise to Professor Garber.

Having applied the Vanguard Method in health, I don't think the problem is one of not enough money.  It is more about how the money is spent.  I have spoken previously about the cost of PFI, NPfIT and the implications of "best practice" in the form of walk-in centres, many of which have been closed as well as other popular management fads.  Add to that the cost of GP and consultant contracts, agenda for change and the colossal waste in the system as a result of its very design (episodic, transactional) you get a sense of the billions that have been frittered away on the back of wrong headed management thinking.  So, maybe there isn't enough money - I shall reserve judgement, but what I have seen does not lead me to that as a conclusion.

In terms of prescription, competition has become the "go to" answer.  For Prof Garber, under idealised conditions, competitive markets lead to a powerful form of optimality.  Ermm...?  In other words, never then - unless there is a hermetically sealed healthcare system somewhere in the known universe.

Competition, he says, is to accomplish allocative efficiency with markets or alternatives (whatever that means) but then goes on to argue that the effects of competition on quality are "generally indeterminate" and the literature shows mixed results but good studies suggest that competitive pressures lead to better health outcomes.  Hardly a ringing endorsement.  Never mind the fact that the studies I have seen are equivocal in their conclusions at best; people like Sir Roger Boyle think it is more an issue of collaboration than competition and that the US healthcare system is the train wreck it is.

The "idealised conditions" argument reminds me of a joke (I forget where I heard it).  A physicist, a chemist, and an economist are shipwrecked on a desert island with only a can of soup to eat and no obvious way of opening it. The physicist's idea is that if they find a stone of just the correct density and use it to apply a force to the can at just the right trajectory that will open it.  "No", says the economist, that will spill the soup.  So the chemist suggests that with the right blend of local flora an acidic compound could be made that would dissolve the tin.  "No", says the economist, the soup will become contaminated.  "What's your big idea then?", say the other two.  To which the economist responds "well that's easy, first we assume we have a can opener".


The fact is, I am still learning, but in terms of order of priority, competition does not come top of the list of things to do to solve the problems of the NHS.  First, understand.  Then, with knowledge, build responses that solve peoples' problems.  Assuming something will work or that you have the conditions to make it work is not a good strategy for change.  I am not convinced the NHS even knows what problem it has to solve.  I am sure that competition will increase costs overall though.

For integration the argument put forward here is that this might be more efficient, leading to better care at lower cost.  It is the way payments are bundled, i.e. the payment mechanism, that will define whether or not services should be integrated.  I don't think so.  In other words, the logic being applied is one of cost, not one of what works.

He goes on to say that integration requires some scope and maybe scale, although they seem to be one and the same thing to me.  Either way, economies of scale are a myth.  You can find out more as to why here.  Systems thinkers know that cost is in flow and it is economies of flow that leaders should be interested in, not scale or scope.  For sure, the fragmentation in the health and social care system (or wellbeing system as it probably ought to be better known) is driving dysfunction and waste on a monumental scale - that much I have seen and can empirically support.  But integration has to be as a result of purpose from the users perspective, not some idea or guess that it will lower costs and improve outcomes.  This is where our opinions diverge and why I say "maybe".


Then there is incentives.  Prof Garber argues that getting incentives right is necessary to achieve internal and external efficiencies under imperfect information.  I really have no idea what he is talking about but to those who still think incentives work I tell them to read Alfie Kohn or look at Daniel Pink's work.  Again, I have empirical evidence that shows how the use of incentives drives the wrong kind of behaviour from a users point of view.  The tragedy is that the impact of it is masked because no-one looks at peoples' experiences end-to-end and the cost to the system of that.


Incentives, the way Prof Garber and others talk about it, will increase costs, not reduce them.

A lot of the patient safety literature talks of errors of ignorance (mistakes made through not knowing enough) and errors of ineptitude (not making proper use of what we know).  My concern is that, based on the thinking of people like Prof Garber and many others who share similar views, management of the public sector is an error of ineptitude on a massive scale.

Rather than looking to experts to give us the answer, leaders in local health economies should be looking to understand their own system, outside-in, from a users perspective and designing responses that solve peoples' problems when they put their hand up for help.  You can only do this by experimenting based on knowledge.  The frustration I have with Prof Garber is that he explicitly recognises the need to experiment and find out what works.  And yet he has a ready made prescription of what works.  It doesn't make any sense to me.

The challenge for the NHS is not to spend time on funding systems, structural issues, accountability and governance frameworks.  Rather it is about asking what the purpose is of what we do from a users perspective and delivering, in full, what people want when they need it.  If leaders are not doing this then they are reading the wrong books.

More from the management asylum - part III

"The drive to personalise mental health care could become a damp squib campaigners have warned", reported the HSJ last week.  An NHS Confederation Mental Health Network Survey of 162 service users found around half would not consider taking on a personal budget.  Vicky Nash from MIND argued that the reasons for this are reduced eligibility for care, cuts and health care professionals taking a paternalistic attitude so users can't actually take meaningful control over their lives.

So why was personal budgets seen as a bright idea?  Presumably some bright spark at the DH (who no doubt was informed by some bright sparks at one of the big four management consultancies) concluded that what could possibly be more personal than giving people money direct so they could make judgements about their own care.  Who could disagree with that?  After all, in your own life you make decisions all the time about how you use your own money, making informed decisions about the most effective way to spend it so that your needs are fully satisfied.  And from a business perspective it makes sense - look at Ryan Air and Travelodge.  They get their customers to do most of the work for them so they don't have to provide staff to do it.  It saves them money.  Why not do it in health?

From a system thinking perspective the starting point is wrong.  The policy is based on opinion rather than evidence.  Better to get knowledge and find out what it is people want and need and design the systems response around that (whether that is personal budgets or not).  Insofar as there is any evidence it is clear that the mental health users surveyed are saying "we don't want to do this".  The systems response - to force them to use it.  The head of joint commissioning for Hertfordshire County Council, Jess Livesley goes so far as to say that "you need to present the opportunity in a way that encourages them to step outside of something they may be comfortable with.  It's about the art of the possible".  Systems thinkers would say that this is the equivalent of the system saying "we have the answer, you flex to our way of doing things", rather than the system getting knowledge and providing what people want and need.  It's the worse kind of management.

Then there is the problem of deployment.  Vicky talks about eligibility criteria.  One of my correspondents tells me of an example of a social enterprise in the North of England.  Awarded £250k by the government to buy a building from the NHS (yes that's right, the government gave £250k of taxpayers money to an organisation to buy a building that the government already owned), the local authority then reduces the grant to the social enterprise by £150k.  Users then complain that they are no longer eligible for personal budgets (the basis upon which the original agreement with the NHS/LA was made).  The cost - £150k of lost revenue.  So the social enterprise ends up with a building but nobody to offer services to because it has lost £300k of revenue.  Service users lose out and the system pats itself on the back about how innovative it has been in being able to save all this money.

The cost of it all?  Well nobody knows.  There has been money spent on trying to work out how much money it's going to cost but the results are equivocal.  As for the pilot sites, it looks like they are not too sure about where they are going with it either.

As system thinkers this policy is yet another example of how management thinking can drive a system further away from the people it is their to help rather than bring them closer together.  To be fair to the government, the stated aim of personal budgets is to do less to people and more with them.  Giving people more choice and control over how they run their lives.  The reality, from a systems thinking perspective, is that it is another opinion based reform that costs a lot of money and leaves people with less than what they started with.

More from the management asylum part II

Yesterday I reflected on the continued fascination with M&A.  Neatly avoiding the truism that making a broken system bigger doesn't make it any less broken, the intellectual powerhouses at KPMG and Manchester Business School sidestep the evidence that mergers do not produce the "shareholder value" anticipated and argue that, if only leaders would pay attention to certain things then, "done right", M&A's can be valuable.  Much of the focus of the benefits were on abstract principles like economies of scale, scale and pace of clinical sub-specialties, restructuring and organisational consolidation.  It wasn't obvious to me where people were in that particular equation, be they patients and their carers or, more widely, citizens.

And this is one of the most common themes in much of the management literature on health.  A great deal of talk about scale, processes, restructuring, return on investment but less obvious is the link back to people.  The major problem is that this kind of thinking is resulting in very poor decisions being reached, is creating a huge and very real financial burden to the taxpayer and is affecting patients.

Part II of the piece concerns more of this kind of thinking.  No, it's not NPfIT, although that surely fits the bill.  The plaudits here go to PFI.  Another Select Committee, this time the Treasury, has panned this government policy judging it to be poor value for money for the taxpayer.  The Government had become "addicted" to PFI, the Committees Conservative Chair said.  The reason?  Because PFI is a means of getting something now and paying for it later.  The situation is so bad that the Committee is calling for PFI debt to be added to the official national debt.  A move that, if it were to happen, would increase that figure by £35bn.

But at least the PFI funded buildings were of higher quality and more innovative in their design than those procured by other means?  It seems not according the the Select Committee.  In fact they found evidence that design innovation was worse and build quality was of a poorer standard than in non-PFI buildings.

How about then that contractors maintain finished buildings to a higher standard?  Well, no, not that either.

Surely then there must be some wriggle room for, in this case, NHS Trusts to renegotiate terms given the tough economic circumstances we face?  Dream on.  These contracts are so watertight that in fact what you have is a situation where the profits from selling PFI equity on the secondary market are more lucrative than the actual commissioned projects themselves.

One study estimated that of 154 projects looked at, if the £500m profit made in selling on PFI equity was applied to all PFI schemes then the overall profit the private sector has made on this element of the scheme alone would be £2.2bn.  What is even more remarkable is that the return on investment on those schemes for which information is available is over 50%.  This compares to a construction industry average of 2.8% over the same period (the last 6 or 7 years).  If you focus on health alone that profit margin reaches 66.7%.

So there you have it.  Yet again, some bright sparks in the DH come up with the "go to" answer.  In this case it is PFI.  The legacy - lots of new buildings and a mountain of debt that is a significant contributor to the funding gap that the NHS is struggling to meet.  A problem that will, undoubtedly result in patients and their carers being adversely affected.

The outrage is that there is one example after another of colossal wasted money in the system and yet the management paradigm that results in someone somewhere thinking that M&A, or PFI (or NPfIT) are good ideas continues.

Apparently Sir Alex Ferguson said that Danny Wellbeck went off on loan to Sunderland and came back a man, annoyingly in time to beat my team last night.  Not quite sure what he meant but in his case that transformation only took one season.  We've spent decades watching debacle after debacle in the NHS.  Perhaps it's time for the senior leaders in the NHS to "man up" and start taking some responsibility for a way of thinking that has damaged public finances and peoples' lives.  Stop frittering away your intellectual capital on thinking that drives the system further away from people and start putting it to good use.  Start basing decisions on knowledge not the work of think (or guess) tanks.  Change your thinking.  And do it quickly.

More from the management asylum - part I

It seems there is a lot to talk about in the world of healthcare.  What to choose to talk about?  I thought I would start the week with the thrill ride that is M&A (or mergers and acquisitions).  For some reason the NHS Confederation posted a link to a report by KPMG on M&A.  They commissioned Prof Kieran Walshe and his team from Manchester Business School to conduct 29 in depth interviews with senior executives from private and public healthcare providers in 12 countries.  The results have then been dressed up in a glossy report and passed off as psuedo-academic research.  I suppose I should be surprised that Prof Walshe has allowed himself to be associated with what can only be politely called a disappointing paper.  But the more I study health from the outside-in from a users perspective using the Vanguard Method, the more evidence I see of shoddy thinking driven by an unswerving belief that this stuff works.  You may want to draw your own conclusions so you can link to the report here.  I would suggest that you don't bother because it adds nothing to our knowledge base of what works and serves only to underline the continuing fascination with management gobbledygook that at best wastes everyones time and at worst is dangerous.

Perhaps I am doing KPMG a disservice.  After all, they do express "surprise" at what were described as "optimistic responses" of their respondents when asked to rate the success of their own merger experiences in terms of whether value was created, reduced or remained neutral.  Apparently 65% of the respondents claimed their deal added value.  This is despite KPMGs own research which shows that only 30% of all mergers meet their financial expectations in terms of share price or shareholder value.  I wonder what that figure would be if they looked at what it did to patients?

In fact, the whole report is littered with fairly compelling, if understated, evidence as to how often M&A's fail.  So why is it that at the very beginning of the report they state that "done right, M&A can be a valuable tool to drive sustainable clinical and financial outcomes"?  Implied from the outset is that, despite their own evidence to the contrary, M&A is a worthwhile endeavour in and of itself.

Why?  Well, because there is the following "heady mix" driving restructuring and organisational consolidation:

• scale and pace of clinical sub-specialisation
• economies of scale
• financial pressures
• payer demand

Hmmm.  Really?  What about those people who want and need services?  What about designing, from a position of knowledge based in understanding your own system, responses around that?  And can somebody please get a grip on this myth that is economies of scale.  John Seddon has written extensively about this but it seems that it remains one of the most pernicious elements of management thinking that is having the perverse effect of driving organisations and their staff further and further away from understanding what people want and need when they put their hand up for help.

It's OK though, because the report argues that so long as senior executives pay attention to:

• defining and enhancing value
• managing stakeholder relationships
• planning and due diligence
• maintaining momentum

all will be well.  I remain less convinced.

My problem with this is that it accepts at face value, contrary to all the evidence, the kind of thinking (i.e. M&A's work) without questioning the principles that drive the idea that M&A's are a good thing.  M&A's then become the "answer" and the de-fact purpose becomes "create the new organisation".

Instead, any organisational change should be based on knowledge about what works for patients.  It may be that by understanding what people want and need you do change how the system responds to it, but you don't do it because it is the latest management fad.  The evidence, to date, is that they are not all they are cracked up to be.

So why focus on M&A today as a topic?  Hardly the most exciting of things to spend one's time considering.

Well the reality is that I am very disappointed in the NHS Confederation for even giving this kind of report any air time.  This, despite the fact that their previous CEO wrote extensively about how M&A's were a triumph of hope over experience.  It doesn't augur well for the Confederation if it remains wedded to these outdated ways of thinking that are long since past their management sell by date.

And I am also worried.  I am worried that the NHS is continuing down a path of transformation that is importing ways of thinking and working that simply do not work.  In fact they could be damaging.  Stoke Mandeville and Maidstone are two obvious examples where the concept of M&A and economies of scale have had tragic results.

What I would like to see is the leaders in the NHS paying more attention to understanding their local health economies outside-in as a system from a users perspective rather than continuing to worship at the altar of management thinking that will not produce the benefits they want or users need.  Unfortunately there are few signs, as yet, that this is likely to happen any time soon.