In our book published last month, Organisational innovation in health services, based on a study of the introduction of treatment centres across the NHS, we followed the way eight of the pioneering NHS centres were created and run in the early days of the last government. The aim was to see how organisational innovations work out in practice. What emerged instead, was a set of detailed stories about the way a major national programme of change was implemented.
These stories showed time and again how easily local circumstances can subvert the policy makers’ best intentions. How a plethora of policies can unintentionally but fatally undermine each other. How ill thought-out central policies can clash with the local running of services. And yet how, despite all these tensions, front line staff can sometimes bring about real improvements.
None of this will come as any surprise to anyone familiar with implementing change in the NHS. Alas, though, it seems the politicians and policy makers are carrying on blithely as if none of it were true.
Our study led to a wide range of suggestions about the art of introducing organisational innovations. Several of our numerous general recommendations were aimed specifically at policy makers and yet, it is plain to see the same mistakes being repeated in the government’s current attempts to reorganise the NHS.
One example of the fairly obvious suggestions supported by our research was that “specific training may be required among managers at all levels of the service. Successful implementation of organisation-wide innovations requires a high level of both strategic and frontline change-management skills, which are often in short supply”.
One wonders how GPs, suddenly finding themselves in the forefront of strategic management of commissioning for which they have never been trained, will be able to solve the problems of running the NHS more effectively. Policy makers seem to assume that GPs, because they understand their patients and problems of health care, will naturally have the right skills. The policy makers and politicians designing the current proposals no doubt found GPs agreeing that NHS managers and commissioners were redundant because the doctors themselves could do the job. But managing the intricacies of commissioning care for a whole population and running one of the largest and most complicated organisations in the world is much more taxing than they assume.
And of course, because there has been too much top down interference, too many wrongheaded targets, and enough maddeningly dozy bureaucrats to give NHS management an unfairly bad name, such a message fitted well with the current political and economic trends. But that doesn’t mean that GPs will actually turn out to be better at designing and running the service than the people who are actually trained to do so.
A simple analogy shows how naïve that would be. We recently had a group of contractors doing various works around the house and found them each of them to be superbly skilled and knowledgeable. Like many people, the builders and plumbers thought that architects, local councillors and solicitors are an expensive waste of space. Yet we would be out of our minds to therefore ask them, in addition to their current jobs, to design our next house, award the planning permission and do our conveyancing. And yet, by analogy, this is exactly what policy makers are planning for the NHS.
Politicians and policy makers claim to be “listening” to concerns about the White Paper. But it is not enough just to hear the arguments (even if they could do so, given that their main listening device seems to be a microphone on a podium). One also has to react rationally. The lack of capacity and relevant skills among GPs is just one of many concerns that have been repeatedly raised but which the policy makers seem to be dismissing.
Which brings us to another of the recommendation that came out of our research: “There should be more rigorous evaluation of innovative policies while they are on the drawing board. Where this reveals strong evidence … that problems will arise from the widespread implementation of an innovation, due caution should be diligently exercised, not swept aside.”
by John Gabbay, Andree le May, Catherine Pope, Glenn Robert, Paul Bate and Mary-Ann Elston, authors of Organisational innovation in health services