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Richard Smith: Will cuts lead to radical change?

7 Oct, 10 | by BMJ Group

Richard SmithOne response to a deep financial cut is to change radically, to do things in a wholly different way. An alternative response is to shrink back to old ways on a smaller scale. I’ve been wondering for a while what will happen with the NHS, hoping for radical change but fearing unchallenging retrenchment.

 I don’t think that the NHS has changed radically in the past five years while it has had a generous infusion of cash. Unfortunately it’s easy to go on doing roughly the same old thing while being given more money. Deep cuts, in contrast, force change, but they don’t necessarily force improvement.

I thought about all this as I listened to a very lively Ruth Kennedy, a “public service innovator,” describe the Total Place project that is redesigning services for children in Croydon. She is the “project conscience” of the programme, urging people to go on with uncomfortable change when the gravitational pull is always to revert to business as usual. Kennedy was talking at the first annual meeting of the South West Academic Health and Social Care Network, which aims to improve working among the NHS, local government, and universities.

 The Total Place project was started by the Treasury and had the aim of both radically improving services and saving money. Its philosophy is perhaps best summed up by this quote from Michael Barber, who was head of the Prime Minister’s Delivery Unit: “In the end, achieving great performance in the public sector…requires unlocking the initiative, creativity, and motivation of leaders throughout the system, rather than just those at the top. This cannot be done without substantial devolution and/or providing the freedoms of a quasi-market. In short, you can mandate “awful” to “adequate,” but you cannot mandate greatness, which must be unleashed.” (Politicians would of course love to “mandate greatness,” but to their eternal regret they cannot. They have to give away power and control to enable greatness to emerge, something that many of them find too scary to be possible.)

 The project in Croydon used some simple but effective techniques to understand the nature of the services they were providing to children. Firstly, the team thought about the whole system—schools, social services, the NHS, criminal justice, everything. Usually people don’t do this: they think about their bit of the system and how to improve it.

Secondly, the team listened to families. Earlier in the meeting we’d heard how innovation comes from users not providers—and how preaching to people about “best practice” is usually counterproductive. People have to live the changes. The families told the team just how awful the services were. Things tend to be OK for the majority of people who have no problems or minor problems, but most of the expenditure is on small numbers of children who have multiple and complex problems. It’s the same throughout the NHS.

Thirdly, the team mapped the journeys of the families through the system and the whole system. The failures of the whole system are best illustrated by the map of the system shown on page 46 of the report. It shows huge complexity and a wide disconnect between the services and those they attempt to serve. This is a system of dedicated people working long hours but delivering poor services overall because they are working in a system that has become hopelessly fragmented and complex.

I suspect that this is true of services all over the country—and the world. But the easy bit—and not so easy and definitely uncomfortable—is identifying the problems. The hard bit is changing radically and fixing them. What was clear from the Croydon project is that radical redesign could not only improve services but also lead to substantial savings.

It could be that deep cuts to services will force radical change and improvement, and the Croydon experiment shows there is amole room for such improvemet. But it’s very hard to make radical change when people are fearful of their jobs, and the great difficulty of radically reforming public services is that “the costs come on two legs.” Radical change means fewer people and the remaining people doing things in different ways, both of which are painful. It also means accepting the deficiencies in what you have been doing, which is again painful.

So sadly I’m pessimistic that the deep cuts that are coming will lead to radical improvement.

Competing interest: RS is a member of the council of St George’s, University of London, which is a member of the South West London Academic Health and Social Care Network and which hosted the meeting. He is unpaid and doesn’t claim expenses as he can easily cycle from his home in Clapham to Tooting.

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