Sir Gerry Robinson's bid to 'save the NHS' sparked much debate. But is outside help really a prerequisite for progress? Clive Savory investigates

What is it like to have an outsider walk around your hospital? When the outsider is a management consultant and is followed around by a BBC camera crew, it must be pretty nerve-wracking. This was the situation for Rotherham General Hospital when Sir Gerry Robinson was brought in to 'fix the NHS'.

This is not the first time an NHS organisation has been visited by a management consultant, but it is probably the most public. Besides old adages like 'A consultant will ask to see your watch and then tell you the time', what can be learned from this very public visit?

TV management consultants have not always had good receptions. Sir John Harvey-Jones, ex-chief of ICI, was brought in as the Troubleshooterto advise family-run firm Morgan Sports Cars in the 1980s. His 'big business' viewpoint clashed with that of the family, who ran a small firm that wanted to stay small. In the end, both parties failed to understand each other, with none of Troubleshooter's prescriptive advice being heeded.

Was Sir Gerry, with his private sector background, any different? In some ways no, his attitude was that good management is good management, irrespective of the industry. Valuable assets should be utilised to their full. He was tenacious in pursuing a specific objective to reduce waiting times, without being distracted by whether solutions needed to be discussed at length by committees.

His solutions were often simple and at nil cost, for example 'start operating lists on time'. He was, however, less elitist, and lacking the dogmatic and patronising tone of Sir John. Sir Gerry asked questions and when he heard good answers, he backed them.

Uphill battle

In management speak, many of the changes made were 'low hanging fruit', easily grasped and leading to quick wins. But do you really need an outsider to help you with identifying fruit? For Sir Gerry a major hurdle was getting to grips with the complexity of the NHS. How do the various professional groups relate to one another? Who is in charge? How much does an activity cost?

As is the case for all newcomers to the NHS, gaining a clear understanding of the service is an uphill battle. Grasping the 'higher hanging fruit', where significant efficiencies lie, is much more difficult. It requires a clear understanding of the overall process of healthcare delivery. Sir Gerry found this wider process view hard to appreciate.

He was careful to back the ideas of both clinical and management staff in the hospital. To his credit, he had the courage to let staff identify problems and develop workable solutions. This may just be because he is a nice guy, but more likely it is because people involved in delivering healthcare services will often have the best understanding of those services.

A major lesson from the programme is that healthcare innovation needs to engage the minds of operational staff. A classic example of the power of professionals taking control of innovation is the development of the leg ulcer telemedicine service at Good Hope Hospital in Sutton Coldfield.

The vascular surgery outpatient service underwent a period of change during which it was given an innovative redesign, and the creation of a one-stop shop for the treatment of leg ulcers, with the capacity to manage image-based electronic patient records, allowing information to be shared between hospital and community-based NHS staff.

The project is an excellent example of staff-led innovation, and resulted in the team receiving both the NHS Innovation Award for Service Delivery 2004 and the HITEA Award for Best Use of IT in the Health Service 2005.

As we have seen with Robinson's work at Rotherham, the progress of innovative projects owes as much to informal as to formal activities. Simon Dodds, the key driver of the Good Hope project, reflected that: 'What is perhaps most surprising is that we achieved this nationally acknowledged success with none of the conventional service improvement machinery: there was no national directive, no business case, no project board, no management involvement, no external financial support, no special training and no service improvement experts. There was just us.'

This brings us back to the core question that arises from Gerry work - can managers, clinicians, nurses and support staff work collectively to deliver benefits for the NHS and its users? The answer is yes. However, while staff can recognise problems and develop solutions, it does sometimes help to have someone ask the right questions, and doggedly encourage and pursue solutions.

Clive Savory is a lecturer at the Open University and has a research interest in technological innovation projects that are led by NHS staff.