Well, well. Looks like you have more impact if you concentrate on outcomes not structures.

Hope you all had a good break.

We return at the start of a crucial few weeks for the NHS. As Theresa May made clear in her speech in South Africa she expects “a sustainable 10 year plan from the NHS to deliver better outcomes for patients”. That means by mid-November, the time of the budget, the NHS will not only have to have worked out, with the public, a new contract with a set of improved patient outcomes but will need a 10 year delivery mechanism to make them happen for real. A busy 10 weeks.

Making this contract with the public, specifically about improved patient outcomes, is a vital part of this process. In 2002, when the NHS was last engaged in planning what to do with extra money, much of what we worked through – then and in 2004 -focused on maximum waiting times. Then, as now, these were important to the public. Waiting time for treatment increases anxiety and needs to be reduced but working much more on the outcomes of all NHS efforts for patients is the right thing to do.

Otherwise too much of what we do is lost in structural change. We believe that structural changes will lead to desired outcomes, but we spend all of our effort on making the structural changes because we believe that will automatically lead to improvement . It won’t. You need to concentrate on the improvement to outcomes.

At the moment a number of STPs (Sustainability and Transformation Plans) say that they will roll out either new models of care or GP federations or any set of the structural changes of the moment. They then expect that those structures will produce improved outcomes.

But the structures by themselves don’t do much. Simply concentrating on creating a new structure means that what you get is a new structure. If you want better outcomes what you need to do is concentrate all the time on the improved outcomes being the success factor NOT a new organogram. You will get a new organogram, but that’s not the purpose of the change.

In August there were reports of two pieces of research which appeared to be contradictory,

First, in the Financial Times 14/08/2018 (p 2)

“Closing hospital emergency departments does not result in more deaths but neither does it improve outcomes for patients”.

Second, reported in the Times (p 17) on 20/08/2018

“Controversial A and E reforms under which ambulances can bypass the nearest hospital have saved the lives of 1600 people since their introduction in 2012. Designating some hospitals as major trauma centres concentrated expertise in dealing with trauma emergencies, which meant that this expertise could save more lives”.

The first of these reports seemed to say that changing hospital emergency services has little impact – doesn’t lead to more deaths but doesn’t lead to fewer either.

The second piece of research seems to say that if you reorganise emergency services around specialist trauma services you save 1600 lives.

At first sight it appears that these findings are contradictory, but actually they aren’t.

When you get two or three long-term NHS leaders together the war stories they will swap will be about the challenges of changing the emergency services in their area and how hard that is. Given the nature of public fears about patients needing emergency services, the public never simply goes along with these changes. There are always long public campaigns, political rows and many of the changes just don’t happen. And when they do, they are several years late, with little impact.

Nearly all the time these changes start off with some form of driver for improved outcomes. Perhaps the variability of outcomes between different A and E departments for example. But as the struggle drags on and on, just making the structural changes is exhausting and so – when something is finally agreed – the structural change has become the dominant issue.

On the other hand if you start with an argument about an outcome and stick to it, the argument, and the change, focuses on the issue of the outcome.

Over the next 10 weeks as the NHS creates its new contract with the public, it will be expected to create better outcomes for the public. In the midst of that process it will be important to understand how to create radical change that drives towards achieving those outcomes.

The current structures don’t, and will need to change.

But if after 10 years all the public has received for its extra taxes are a set of new structures they will want their money back. And they will be right.

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