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Dear Alistair,
I'm on the train reading your 'Editor's opinion' challenge: that leaders should question and not answer. I have been pondering on some questions on my mind and wondered what the answers might be:
Questions on a Train
1. Tolerating excellent and poor performance and doing nothing about either reinforces mediocrity. Why don’t we positively reinforce good performance by rewarding those organisations that consistently deliver high results?
2. Within an organisation we find normal distribution of staff contribution to goals and values – with poor, average and excellent contribution. Why don’t we use the freedom of Agenda for Change arrangements to introduce robust assessment and assure that access to the 3 ½% incremental pay advancement is directly associated with contribution rather than provided on the anniversary of appointment?
3. Organising the management of knowledge is difficult. Getting best practice reliably into practice requires a change in traditional mindset and relentless discipline to assure adherence. We have limited experience and even less success at doing this. What new skills will leaders require for this?
4. Providing a two tier service (weekday and weekend) harms patients and traps inefficiency in our systems. Do we have the courage to set new service standards for patients so they can have highly reliable services – any time of the day and any day of the week? Do our senior managers and clinical leaders act as role-models by routinely working at weekends as part of their working arrangement?
5. Variance of practice leads to variance of outcomes. What are the effective governance arrangements which the NHS should have for assuring consistently high standards of primary care practice?
6. Improving our health care systems requires a new understanding or measuring (not benchmarking) for improvement. Do Boards really understand the difference in data sources and how to read run charts/statistical process control charts to drive improvement?
7. Better care, better outcomes and lower cost will follow from hospital provision being organised to serve populations of c.1m. How do we change the incentives and create win–win opportunities so that Trust CEOs embrace change positively rather than defend the status quo? Isn’t it odd that there are so few models and experimentation of joint venture SPVs for Trusts to share benefits of rationalisation of scale and scope of services?
8. Too many patients still experience avoidable harm within our systems. Will organisations be bold enough to publish, at the beginning of the year, what improvements to patient safety they will make and then report publicly their improvement in their annual quality accounts – rather than congratulate themselves on what they have done without saying what they had intended to do?
9. The tsunami of alcohol related admissions (77% increase in 10 years) is having deep impact on our health systems and our society. Do we have the will, ideas and disciplined method to change this?
10. Most sustainable ideas for change are found deep inside an organisation – and few are found at the top. The same is true for the NHS as a whole. How do we encourage both deep engagement with staff inside organisations as well as supporting organisations to network with like-minded ones to test new ideas and implement change together - rather than accept the ‘wisdom’ from above?