On the first page there is even a logo. It says "Time to Think Differently". How true. Common sense really. Why wouldn't you design a system against the demands that are being placed upon it?
They go so far as to say the health and social care system is broken. They argue:
"patching up the existing system will not deliver the transformational changes required. Nothing less than a sea change in thinking and action is needed to tackle the fundamental weaknesses of a system that remains focused on addressing yesterday’s problems rather than anticipating what will be needed in future." (p 26)
Wow. A sea change in thinking. Absolutely. You'll find no argument with that conclusion here. But to think that, after all the massive upheaval that the health and care service has undergone, the Kings Fund still calls for "radical change". It defies belief really - how could our best leaders, supported by the keenest brains in the country, have got it so wrong?
The document outlines a range of different things that the NHS should do. Common sense really. Who wouldn't agree with greater user involvement, or eradicating arbitrary boundaries between organisations, or more appropriate settings for care. Certainly it is what my studies have led me to conclude, often leaving me bewildered at the lack of common sense approaches to solving peoples problems.
Which got me thinking about common sense. From what I have seen common sense means leaders believe in a number of things. Things like:
- Economies of scale: if you have £20bn to save/not spend/find (however it is described) it makes sense to simply do more of the things we "know" work. Just do it at a bigger scale and do it quickly. Merge with another organisation for example. That way you get the benefit of savings in two ways:
- less of a common resource (managers, buildings, kit etc) (yes, but marginal) and
- lower transaction costs through industrialisation of services (not true)
It's self evident, isn't it. Just common (non)sense.It's not rocket science. How difficult can it be to specify precisely what is needed? Just common (non)sense.
- Managing costs makes costs go down. Cheaper = breaking tasks down into their functional elements as it is best to get your most expensive resource focussed on doing the high end stuff, not the easy stuff that anyone can do. The beauty of this approach is that it allows leaders to be free to industrialise services.
Stands to reason. Reduce your unit costs and you save money. Just common (non)sense
- Industrialising services saves money. Back and front office functions split, call centres, outsourcing of services, shared services. That makes perfect sense too doesn't it? Separate the simple from the complex tasks; have your experts doing what they are paid for and the less skilled doing the less complicated. Better still, outsource it. Get people whose specialism is dealing with the sort of flows that you really don't want or need to spend the time dealing with. This approach has the added benefit of allowing you to specify service levels - what you expect to be delivered. That way you can have the triple benefit of not doing the work yourself, performance managing services provided by other people against an agreed set of criteria and, best of all, managing your costs.
- Standardisation makes things easier, safer, improves quality and makes it easier to train people. So it should be done everywhere. Plus, if it's done really well tasks can be broken down even further, so cheaper labour can be deployed to complete those basic tasks
It works in manufacturing, so we need to do more in services. Just common (non)sense
- Harness technology too, especially at scale. Put the brain in the computer. If you have already standardised, functionalised and specialised, use technology to do it even more efficiently. Even better, you can get cheaper labour to operate the computer. Don't worry if you haven't already standardised etc, an IT solution will do that for you anyway
What could possibly go wrong? Just common (non)sense
If the financial benefits don't materialise that's OK. Just set a target, or create a new incentive, or maybe exercise a contractual penalty or two. It's all well and good talking about systems, but they are made up of people so lets manage them with targets, incentives and penalties, because people are the real problem.
Never did me any harm. Just common (non)sense.
And once you have scaled up, paced up, targeted, merged, specialised, functionalised, standardised, rationalised, incentivised and, maybe, prioritised you will have created the perfect mix to generate efficiencies and protect, perhaps improve, quality. So long as you have made best use of best practice. No point in re-inventing the wheel, especially if we know a particular model of care works. Not only can you simply adopt what has worked elsewhere but it comes with the added bonus of being able to benchmark performance against.
That is just sensible. Just common (non)sense
Well so long as you haven't forgotten to plan. Particularly if you are going to do something as complex as an IT change programme. Planning will guarantee success and enable the benefits of all the other things you've done to be delivered. Milestones and RAG ratings are particularly helpful. Crucial even.
Now that really is just common (non)sense. Can we please just get on with it.
Except, it isn't common sense at all. It's all common nonsense. They are beliefs that drive waste and harm service delivery on a monumental scale. And they are present in virtually everything you see or read about the NHS and care services because our leaders are blind to it. Even the Kings Fund report, as radical as it may seem at first pass, to me falls into many of the same thinking traps, inevitably diminishing any benefits its good intentions would seek to deliver.
In the rush to provide answers we are forgetting to ask basic questions. What is the purpose of what we do, from a users point of view? What matters, from a users point of view? Get knowledge based on these principles. Develop relationships, design against demand and design for continuity. Do that first. Don't "plan" or "specify" or "implement best practice", not if you really want to transform.
In my next post I will provide an example of how a private client that has transformed its business by ditching current convention and asking those simple questions. And by embracing the counter-intuitive truths they discovered when they looked at their business outside in, from a users point of view. They went slow and the benefits came thick and fast.
You can draw your own conclusions from what you see but, from my perspective, what is missing in the Kings Fund paper is method. Change thinking? Definetly. But this does not mean change thinking about what structures or service models will work. It means first unlearning all those things we take for granted as management truisms - then learning to design responses to solve peoples problems. From this micro understanding the macro solutions will emerge.