Muir Gray: Meeting the Trish Greenhalgh challenge

Muir GrayIn the debate about the NHS reforms that occupied so much Twitter space before the Health and Social Care Bill was passed, Trish Greenhalgh quite properly challenged me to use the five whys approach that Taiichi Ohno used within Toyota and that I had been advocating be used for other issues, to drill down to the root of a problem, and to support my contention that reform was necessary. [1]

I said in a blog in March that I did not believe we could claim to have a National Health Service if we were unable to answer simple questions such as, “Is the service for people with asthma in Somerset better than the service in Devon?” I argued that we had a national health access, but not a national service if we were unable to compare the service offered one population with that offered another similar population. So here are the five whys, and my answers:

Q1. Why do we not know if asthma care is better in A than in B?
A1. Because information services focus primarily on institutions and not on problems.
Q2. Why do we collect information about institutions and not diseases?
A2. Because we have managed healthcare since 1948 by the institutions that were inherited in 1948—hospitals, community services mental health services, and GP teams.
Q3. Why do we focus on institutions?
A3. Because the managers of health focus on institutions not on health problems.
Q4. Why do the managers focus on health service institutions, not on health problems?
A4. Because so few of the people who manage have profound knowledge clinical issues.
Q5. Why do so few of the people who manage health services have profound knowledge of clinical issues?
A5. Because clinicians have not stepped forward in sufficient numbers to fill senior management and leadership positions and accept responsibility for the stewardship of the service

The  recent changes require the clinicians to accept responsibility for stewardship and enough are willing to do so, so I am confident that we will be able to answer the questions above within five years, but, then again, I have been very confident about this for the last 30 years. [2]

1. Ohno T, The Toyota Production system

2. Gray JAM (1983)
Four box healthcare; development in a time of zero growth Lancet 2 1185-1186

Muir Gray is visiting professor of knowledge management, Nuffield Department of Surgery, University of Oxford.

  • Chris Hewitt

    Very interesting thank you Muir – as a GP in a leadership role I accept your premise in answer A5 above…however I think 5 whys may not have been enough to get to the root causes…the next why might be why have clinicians not stepped forward in sufficient numbers to fill senior management and leadership positions and accept responsibility for the stewardship of the service?

    I’m afraid there may be many answers to that – each of which require many more whys to probe further. My understanding is that the Toyota model used by Taiichi Ohno often needed many more than 5 whys following a number of roots to get to the nub of complex issues. I suspect in 3 years time many GPs and other clinical leaders who will have “stepped up to the plate” (or whatever UK politicians say these days) will feel very vulnerable as blamed is heaped on them…perhaps we may look back and think not enough questions are being asked (and answered) to avoid them from being set up to fail…