By Accountable Care Journal-
While waiting for a flight in the departure lounge of an airport recently, I asked the pilot when we were expecting to leave. He dug out his tablet, swished about with his finger and said the inbound flight was the other side of Glasgow and would be on stand in 20 minutes. I asked about refuelling and the stacking over Heathrow and his trusty tablet told him everything.
As he left to do his pre-flight checks, I reflected that I could not have had such a conversation with any NHS manager, nurse or doctor. But then, pilots did not talk that way, either, when the NHS was born, 70 years ago.
It is tempting to look at the pilot’s world of timely figures and tracking information and to prescribe the same for the NHS. But what is it about flying or any of a dozen other sectors that has transformed them ahead of the NHS?
The answer involves two deceptively simple ideas – knowledge and process. Leaders in these other sectors were not specifically seeking knowledge or process but invested in them relentlessly because they were chasing something else – something that is critical to the NHS today.
Surprisingly, it was a deep-seated aversion to waste that drove this change. By the 1960s, for instance, supermarkets could see that delay in getting produce to the shop was a waste, not just because food goes off, but because the supermarket must spend money on a product right up to the moment a sale is made. Walmart’s investment in computer systems, barcode scanners, smart tags, and networks in the 1970s is testament to a frighteningly expensive war on waiting.
In the 1990s, a decade before the NHS attempted its national IT network, Walmart spent a similar amount on its own network, persuading its suppliers to invest considerably more, and made it work. The reason the NHS failed while Walmart succeeded was that the NHS had no clear idea of what waste the network was meant to eliminate, while Walmart knew exactly how the network would help make better decisions faster and how much decisions were worth.
Today, health researchers all over the world are working hard to identify waste in all its forms; from the obvious waste of prescriptions and treatments that are not needed to the less visible business of variation in practice. Lord Carter, for instance, has shown that similar NHS services can cost wildly different amounts to run, depending on where they are. So, what is holding the NHS back from a decisive victory over waste?
Firstly, many in healthcare find it at least as distasteful to express waste in financial terms as they find the waste itself. This is understandable to some extent since many NHS staff encounter several examples a month where money, or the paperwork that goes with it, comes before the patient. However, without a more reasonable relationship between the NHS’s mandate and the resources that make it run, there will always be significant, invisible waste.
Secondly, one cannot reduce waste without metrics, and the NHS struggles with measures of effectiveness. Too often these are associated with punishment, not often enough with polishing the process. Winning the war on waste will need better metrics applied in better ways.
Finally, if other sectors are anything to go by, waste often hides in the most unlikely places. The fact that a ward is full, or that the list at a surgery is overflowing, does not tell us whether either is efficiently run. It usually requires information from a long way back as well as knowledge of the wider service, to judge what is going on.
Given robust definitions of waste, however, the ingenuity of the NHS could be unleashed to track and eliminate it. The NHS employs some of the brightest people in the world – robust design and technology empowered delivery is not beyond them, nor is affordable, high quality, care at scale. What the NHS needs now is a clear target and the will to pursue it relentlessly.
Professor Terry Young worked in industrial R&D before becoming an academic and is now Director of Datchet Consulting. With over 30 years' experience in technology development and strategy, health systems, and methods to ensure value for money, his current focus lies in designing services using computer models and he set up the Cumberland Initiative to support healthcare organisations wishing to develop their services more systematically. Three of his downloadable papers are:
Using industrial processes to improve patient care (2004, with Brailsford et al., British Medical Journal)
Performing or not performing: what’s in a target? (2017, with Eatock & Cooke, Future Hospital Journal)
Systems, design and value-for-money in the NHS: mission impossible? (2018, with Morton and Soorapanth, Future Hospital Journal)
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