{"id":4732,"date":"2010-10-07T11:46:52","date_gmt":"2010-10-07T10:46:52","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=4732"},"modified":"2010-10-07T11:46:52","modified_gmt":"2010-10-07T10:46:52","slug":"richard-smith-will-cuts-lead-to-radical-change","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2010\/10\/07\/richard-smith-will-cuts-lead-to-radical-change\/","title":{"rendered":"Richard Smith: Will cuts lead to radical change?"},"content":{"rendered":"

\"RichardOne 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\u2019ve been wondering for a while what will happen with the NHS, hoping for radical change but fearing unchallenging retrenchment.<\/p>\n

\u00a0I don\u2019t think that the NHS has changed radically in the past five years while it has had a generous infusion of cash. Unfortunately it\u2019s easy to go on doing roughly the same old thing while being given more money. Deep cuts, in contrast, force change, but they don\u2019t necessarily force improvement.<\/p>\n

I thought about all this as I listened to a very lively Ruth Kennedy, a \u201cpublic service innovator,\u201d describe the Total Place project<\/a> that is redesigning services for children in Croydon.\u00a0She is the \u201cproject conscience\u201d 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.<\/p>\n

\u00a0The 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\u2019s Delivery Unit: \u201cIn the end, achieving great performance in the public sector\u2026requires 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 \u201cawful\u201d to \u201cadequate,\u201d but you cannot mandate greatness, which must be unleashed.\u201d (Politicians would of course love to \u201cmandate greatness,\u201d 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.)<\/p>\n

\u00a0The 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\u2014schools, social services, the NHS, criminal justice, everything. Usually people don\u2019t do this: they think about their bit of the system and how to improve it.<\/p>\n

Secondly, the team listened to families. Earlier in the meeting we\u2019d heard how innovation comes from users not providers\u2014and how preaching to people about \u201cbest practice\u201d 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\u2019s the same throughout the NHS.<\/p>\n

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<\/a>. 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.<\/p>\n

I suspect that this is true of services all over the country\u2014and the world. But the easy bit\u2014and not so easy and definitely uncomfortable\u2014is 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.<\/p>\n

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\u2019s very hard to make radical change when people are fearful of their jobs, and the great difficulty of radically reforming public services is that \u201cthe costs come on two legs.\u201d 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.<\/p>\n

So sadly I\u2019m pessimistic that the deep cuts that are coming will lead to radical improvement.<\/p>\n

Competing interest: RS<\/strong> is a member of the council of St George\u2019s, 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\u2019t claim expenses as he can easily cycle from his home in Clapham to Tooting.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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