- Improving health care
- Locality working
- Dumb doom
- No money required
- How ministers respond
- Nearly ready
- More dumb lean
In last week’s news we heard reports on demand rising in health care services; accident and emergency and general practitioners are, apparently, feeling the strain and the Whitehall voices, as ever, think this is a problem of resource management. It is not, and to treat it as such is to ignore the most important lever for change.
Our health services are stuffed with failure demand. Last week I spent two days with our experts in health. It was both illuminating and profound. For example, I was shown how the preoccupation with length of stay (LoS in NHS parlance) actually increases the consumption of resources (i.e. longer overall stays), yet it is considered to be the lever for reducing them.
The lever for reducing resource consumption – in any system – is managing value. We published an example in stroke care, where managing value led to the LoS dropping from an average of 16 days to 6, which meant the unit needed 39 beds, not 56, the cost per patient fell from £6k to £3k and the mortality rate went from one of the worst to one of the best.
The NHS employs ‘bed managers’ whose focus is to free up beds. It’s the same logic as focusing on LoS, it will result in more bed utilisation, not less. In the example above the number of beds required fell because the service was improved; simple.
The tariff for stroke care is £4k. In NHS parlance the case above moved from making a loss of £2k to a profit of £1k. Bonkers, the tariff should be 3. It is counterintuitive, commissioning on cost gives you lower costs.
To take another example: studying and redesigning an outpatient clinic reduced waiting times dramatically, cut end-to-end times for patients (who loved it), increased the capacity of the clinic, so more patients could be seen and, in NHS parlance, went from making a loss to making a profit. Again, bonkers numbers; why do we treat health care as needing to make a profit?
The fundamental problem in health is that the NHS is still designed the way it was when it started, but the nature of demand has changed. The eye-watering plethora of ‘initiatives for improvement’ (you wouldn’t believe how much of it there is) merely focus on problems people think they have and do nothing to affect the structural/systemic problem. The management preoccupations with eligibility (gate-keeping) and productivity only serve to worsen the provision of services and increase failure demand.
We will be putting on a conference on the Vanguard Method in healthcare in the New Year. If you want to be notified please contact Charlotte: firstname.lastname@example.org
The October conference on Locality working was over-subscribed. So we are going to put on another in the New Year. I think this is the most important work we have done in the public sector. Studying what happens to people whose lives fall off the rails reveals that we spend loads of public money and don’t help them. In two locations we have helped clients build designs that do help.
The work reveals the following counterintuitive truths: Demand is stable (not rising), demands are simple (not complex), we have plenty of capacity (no financial Armageddon), we have an effectiveness problem (not an efficiency problem) and when we provide services that meet needs, we improve. Costs fall dramatically and, most remarkably of all, demand falls. Yes, fewer problems in families and communities – isn’t that what public service ought to be about?
If you want to be notified of the next Locality working event please contact Charlotte: email@example.com
The unthinking in Whitehall parade something called the ‘graph of doom’ – it claims to show that by 2024 all the money in local authorities will be consumed by statutory social care services. It is completely without foundation and based on the incorrect assumptions above. It gives politicians something to talk about and will only lead to them dreaming up bad policy ideas.
I have spoken to some people in Whitehall about our Locality work. They say ‘we know all this and that’s why we are investing in ‘community budgets”. I reply to say that this change requires no investment and where people are getting together to plan how to spend their ‘community budget’ money, they come up with plans that show no understanding of demand, they invest in things like IT systems (that’ll waste money), and they do nothing to tackle the fundamental problem I am describing here: the structural/systemic problem.
My experts’ advice to people who sit around in ‘community budget’s’ meetings trying to decide what to do: Go get all assessments conducted by all parties on a group of people drawn at random from the population that makes demands for services. For each person, read all assessments and ask this question: What do we know about the person? It’ll make you sit up.
Major private-sector providers of public services have been found to be ripping us off: putting in invoices for work that wasn’t done. If someone was fixing your house, or whatever, and did that to you, what would you do? What do ministers do? They say once the business has been through a period of ‘corporate renewal’ (whatever that means), we’ll give them more work. Explain that.
Iain Duncan Smith’s Universal Credit programme has, as I predicted, run into massive problems and Duncan Smith is roundly criticised by Select Committees. What does the minister do? He says he’s changed the leadership of the programme and is improving its governance. That’ll do it.
Remember, you heard it here first; UC will fail; guaranteed.
The revisions to the new web site are almost complete. We’ll be in touch with those of you who want to engage with the site and us in improving services in the next couple of weeks.
To register your interest in using the site (you must be people who want to use it to study and redesign services – we need a community of practice, not opinion!) please contact Emma Ashton: firstname.lastname@example.org
If you haven’t been to the site, here is the link: www.vanguard-method.com
I’m going to Sweden this month to speak at their annual public-sector jamboree. It will be my third time. I’m speaking alongside a public-sector client that has made profound improvements in adult social care.
Every time I have been to the jamboree they have had an American lean guru spouting nonsense and this is no exception. This time it’s the guru who claims lean fails because it is what he calls ‘fake lean’ and his lean is the way to go! His ‘real lean’ starts with ‘respect for people’. I can imagine ‘respect for people’ events and tee-shirts (he sells tee shirts) while there is no change to the system conditions that drive misery and other forms of sub-optimisation. Only in America; the home of the terrible diseases.
What would you call a profound idea in this guru’s head?
This tourist will be going on from Sweden to Norway, for their big annual lean event. They know lean isn’t working and they know I know why 😉