Real healthcare reform requires a fundamental change in thinking, because more of the same just won’t do the trick, says Ann Porter, founder and chief executive of social innovation company Soda.
There is an urgency to prepare for the future of the NHS in a fundamentally different way. The time has come to shift choices about healthcare reform into a new conceptual landscape.
In the future, large-scale innovation will be achieved through new definitions of business and new competencies - not through technology, restructuring exercises or the replication of tried and tested service improvement ideas. We have to find and embed new knowledge because more of the same won’t do.
From its inception, the NHS has had to deal with the problem of finite resources and infinite need. The early assumption that costs would decrease as the population became healthier proved to be wrong.
The NHS has always faced changes in the environment, demographics, technology, the economy, lifestyle choices and public expectations. This is nothing new. From the beginning, successive governments have all known that something has to be done to improve returns on health investment.
What is surprising is that over the last 30 years, in their attempts to do something, governments of all political persuasions have consistently applied the same ‘solution type’, even though it has been shown not to work. A certain world view and cognitive style have prevailed. It’s not that the solutions themselves are the same but the assumptions or received wisdoms that underpin reform choices are accepted as doctrine year after year.
The founding assumption of the NHS - that costs would decrease over the years - proved to be totally wrong. What if our politicians and policy makers are building layer after layer of increasingly labyrinthine healthcare reform solutions on top of an edifice that is teetering on faulty foundations? What if they have got it wrong?
What is the prevailing world view?
To understand the prevailing world view, let’s expose two received wisdoms to a common sense reality check.
Received wisdom 1: changing structures changes what people do
A favoured measure to achieve reform has been to merge, build or demolish structures. There has also been a growing movement to take this thinking one step further by turning NHS organisations into not-for-profit enterprises such as social enterprises, community foundation trusts, community interest companies, charities, co-operatives or mutual societies based on the John Lewis model – even though it seems to have escaped everyone’s notice that NHS organisations are already social enterprises. The assumption is, however, that business-like structures or new forms of incorporation will drive business-like behaviours.
This solution choice emerges from a mechanistic world view. If organisations are seen as machines with the people in them as component parts or units of production, then it is logical to assume that a new structure will change what people actually do in a uniform, predictable way. This reform choice has been applied consistently over the last 30 years.
What is surprising to the external observer is that as each new restructuring exercise is announced, a kind of restructuring amnesia seems to occur. There never seems to be a review of the impact on customer satisfaction or economic satisfaction of previous restructuring exercises.
This reform choice is intellectually tempting as it imposes a spurious order on a messy environment and gives an illusion of control. It is, however, an illusion because it does not match the reality of how complicated human beings actually think, act and behave in organisations.
Culture change demands an unravelling and re-knitting of all strands of organisational DNA, particularly everything to do with people and their competencies and motivation. We have every reason to believe that assumptions about restructuring are erroneous. There exists a huge body of literature to tell us that people, their emotions and human relationships are at the heart of organisational change - not structures.
It is interesting to note that when the latest restructuring exercise is introduced to the NHS in a systemised, top-down way, the focus is on ‘organisation as machine’ and not the complicated human beings in it. When the restructuring exercise fails, it then becomes the fault of people. This seems unfair.
Received wisdom 2: Innovation will be achieved by replicating tried and tested ideas because people in the NHS are resistant to change and incapable of disruptive innovation.
Can this be true? There is a simple flow of logic here. The NHS employs 1.7million people. These people are individuals with interests, personal attributes, families, histories, values, emotions, knowledge, foibles, follies, frailties, drivers and passions. They are complicated human beings.
The NHS is 1.7million people, not one amorphous mass. It is reasonably safe to assume that a significant percentage of that amount of people have the same enterprise potential as any other section of the population - given the right conditions and the right help. This is just common sense.
When people join the NHS, they are not suddenly imprinted with “NHS Bureaucrat” all the way through like a stick of rock. The NHS is full of very talented individuals each with huge entrepreneurial potential.
The notion that the best way to innovate is to replicate and diffuse ideas through the system is also not terribly convincing. A cursory examination of how innovation actually happens in science, art, literature and business over centuries shows us that innovators don’t adopt a tried and tested idea and happily implement it elsewhere.
Innovation is the tool of entrepreneurs and this is not how they think or act. Entrepreneurs are ambitious. They will scan the environment to find the edge of thinking but then will strive to go further, because they think they can do it better. This is not the same as adopting a tried and tested formula, factoring in contextual information and then replicating the formula. The human drivers and emotions are totally different.
The belief that innovation can be scaled up by diffusing new ideas through a system just doesn’t fit what people actually do. Ironically, in attempts to eradicate wasteful bureaucracy, the “replicate and diffuse” approach to innovation is in itself bureaucratic.
The prevailing world view that drives healthcare reform choices is mechanistic and bureaucratic. Decisions are underpinned by the assumption that people are units of production who will behave in rational, predictable ways given a certain set of uniform circumstances. A spurious order is imposed on a messy environment and there is an illusion of control.
This is a world view that is high on IQ but low on EQ. It just does not match the reality of what complicated human beings do. We shouldn’t be surprised at this. One of the biggest bureaucracies in the world, like every other discipline or profession, is going to apply theories of choice and decision making that it knows.
We now have to find the energy and the courage to challenge accepted doctrine and to shift reform choices into a totally different conceptual world.
A new definition of business
Just as the NHS emerged from a social movement, next generation development requires the bringing together of NHS entrepreneurs on a single innovation platform - from within and grassroots upwards.
The time has come to make a value leap from an administrative managerial economy to an entrepreneurial one.
Large scale innovation can only ever emerge from new ways of doing business and new competencies. This is what will transform the very fabric of the NHS.