Scale and Pace

Further, faster, harder, deeper - even wider.  And no, it's not part of a script from an adult movie.  It is a common leadership rallying cry - the urgent need to do important things at scale and pace.  Do it big, quickly and by everyone.

Scale and Pace

It is a beguiling concept.  We know what needs to be done so lets get on and do it, goes the logic.  There is the huge NHS change agenda, a change on a scale so big "it can be seen from space"; the need to find £20bn of savings whilst delivering better quality care and outcomes; and lets not forget the challenge of integration, nor that of inspection and regulation, never mind competition.

All of these are large scale problems.  We have to do it and do it now.  After all, there is enough evidence of best practice, isn't there?

There is only one small problem.  Well, maybe two.  According to the evidence, scale initiatives, even those delivered at pace, don't work.  According to Kotter (1995) and Beer and Nohria (2002) up to 70% of large scale changes fail to meet their stated objectives.

Despite the rallying of troops, consultations, pauses, meetings and inspirational calls to arms to get everyone to play their part - to get on the bus or go home; - despite the drive for rapid results (the thought leaders have all read Kotter after all); despite creating a sense of urgency around a "burning platform", it seems large scale change programmes are destined to fail.  David Cameron agreed, committing to no "more pointless top down reorganisations".  Jeremy Hunt, the new Secretary of State for Health went so far as to say "it is completely normal (for a contractor) to fail to deliver on a major project" when commenting on the G4S debacle.

You do not have to go too far to find evidence of the failure of scale projects.  In "The Triumph of Hope over Experience" Nigel Edwards elegantly demolishes the belief in mergers and acquisitions, citing international evidence that only 30% of M&As deliver on their stated aims.

Countless critiques of reorganisations (Smith et al 2001; Walshe 2010 amongst others) have highlighted the deleterious effects and unintended consequences of large scale organisational changes.

Then there are the operational disasters where billions of pounds have been wasted on bright ideas with little or no discernible benefit.  The list is endless, but includes NPfIT, PFI and ISTCs.

Seddon has also written on the myth of economy of scale and many of the damaging logics that underpin it as a concept including standardisation, specialisation and functionalisation.  Although many talk glibly about the benefits of economy of scale, there is so much less said about diseconomies of scale and the huge levels of failure demand that are generated as a result.

Yet despite all this evidence, the Kings Fund today called on Jeremy Hunt to be brave enough to lead long overdue service changes at faster pace.  Along with the dizzyingly complex changes enacted by his predeccessor this seems, to me, to amount to a recipe for disaster.

And so to the second problem with the scale and pace approach - if that the fact they don't work is not enough.  And that is that it makes assumptions about what works at both an organisational and service level that is opinion rich and evidence light.

My studies revealed a counter intuitive truth when I discovered that it is only by understanding the micro that the macro changes can emerge.  By genuinely understanding people in the context of how they live their life and designing responses to and for them in relation to that knowledge, not only are their lives transformed but so is the system of provision itself.

This means investing the time in developing and tending to relationships end-to-end over time.

It is from understanding purpose from a users point of view, using measures that relate to the delivery of that purpose and designing from studying and experimenting rather than "planning" or "specifying" that the cost of stroke care in Plymouth was reduced by half; that non-elective readmissions reduced by 45% in Somerset.

Ironically, by taking the time to understand people and the problems they need to have solved, testing solutions, not just implementing them and understanding that the root cause of poor system performance is the system design not the people in it provides far more rapid results.  It also delivers costs reductions by managing value (not cost) which are far in excess of anything that could be conceived through conventional thinking as these case studies show (I'm Amy, Velcro Man, Plan B)

The conclusion from my studies is that the scale and pace mantra is a garrotte that strangles the life out of innovation, increases costs and drives waste.  So my message to the new SoS is not to buy into the conceit that scale and pace works and that there are think (or guess) tanks that have the answer.  Better is to go slow to go fast.  Help people take the time to understand their patients in the context of how they live their life and the means to design responses that solve their real problem.  From that the changes you desire will emerge and the NHS will genuinely transform.