'Clinical engagement cannot be considered too expensive now'

When the King’s Fund began its review of leadership in the NHS last year, it looked for some new and inspiring fellows to bring in a fresh approach. Among them was Richard Bohmer, a New Zealand trained physician, professor of management practice at Harvard Business School and author on designing healthcare.

Dr Bohmer has some interesting insights into the challenges facing healthcare systems in the developed world – an ageing population, rising demand linked to lifestyle choices, rising public expectation, changing workforce – but wants to get one thing straight. He is not, and does not wish to be seen as, someone who flies in from abroad to tell the NHS how to sort out its problems.

He argues that the commonality of the challenges faced by healthcare systems in the developed world is leading to a shared understanding internationally of how healthcare organisations must operate to meet them. The same questions come up everywhere, he says.

“Everywhere I go, the health system is costing too much. Everywhere I go, the sense is that we are not getting the value or quality we would like given the amount of money we are spending. There are some universal problems.”

We have seen the “it’s too expensive” scares before, but Dr Bohmer says there is something different about the scale of the challenge this time around.

“There is a sense this time that it really is serious. It is the national debt, and the relationship between the debt and the global financial crisis and the domestic economic impact that is new. At the meetings I go to, people are taking this very seriously.”

Yes, the detail varies from country to country but not the big picture. The solution lies not so much in medicine itself, but in how we deliver or organise healthcare, says Dr Bohmer. “Individual excellence is no longer a sufficient condition for good patient outcomes. You need excellent organisations for people to deliver excellent work.”

To illustrate the point – and Dr Bohmer acknowledges this is rather glib – he says: “I ask my students if they would prefer to be treated by a B grade doctor in an A grade organisation or an A grade doctor in a B grade organisation. I think the correct answer is the former. A badly run organisation can undo the work of even good doctors. The majority of safety failures are organisational failures – failures of systems or processes.”

So what does an A grade organisation look like? A good question, he says, but is hesitant to say exactly “because there is geographic variation and there is no single best way to run an organisation”.

Rather, Dr Bohmer talks about what good organisations have in common. In a paper in the New England Journal of Medicinein December last year, he characterised the “four habits of high value healthcare organisations”. He describes how, although they differ in structure, they have some common characteristics – and argues these may be portable.

In brief, high value organisations specify decisions and activities in advance and in detail, setting out specific pathways for highly defined groups and sub-groups of patients. They design microsystems to fit around these pathways, microsystems that include the staff, information and clinical technology, physical space, business policies, and processes and procedures that support patient care.

They measure what they do, for regulators and other external audiences, but more so for their own internal performance improvement. They also review what they do, making sure clinical practices are consistent with the most recent science; thus clinical practice is no longer the domain of the individual clinician.

Fundamental characteristic

The final characteristic, not mentioned in Dr Bohmer’s paper but uppermost in the NHS, is financial stability. “In virtually everything I have said, you have to take the financial stability of an organisation as a given,” he says. “It is a fundamental characteristic. But financial stability flows from many of the other characteristics.

“Those [organisations] that tend to focus on learning tend to be more financially stable. Those that measure cost and outcome know what their costs are and take the view of ‘no margin, no mission’.”

And this is where things get tricky for NHS chief executives. “The dilemma I detect – and I have no data other than conversations – is chief executives asking how, in the face of financial instability, can they realise these characteristics for their organisations? It is very convenient for me to say that financial stability flows from them, but it’s chicken and egg.”

Dr Bohmer says the starting point for organisations seeking to be “high value” is clinical leadership. “It requires skilled leaders of all disciplines, nursing, medicine and so on, to run really effective organisations at a local level,” he says. “Realising the goal of creating good organisations would go a long way down the agenda of better quality care at an affordable price.”

As part of the leadership review, Dr Bohmer interviewed Chris Ham, chief executive of the King’s Fund, and asked him if clinical leadership was a “must have” or a “nice to do”.

“Chris’s answer was yes, we need to engage clinicians in clinical leadership to solve the financial as well as the quality challenges,” he says. “And to me trying to engage earlier rather than later is a better bet. But it is a dilemma and I recognise it as such.”

His suspicion is that chief executives of financially challenged organisations are not going down this route. They may prefer to identify less profitable services, close them down and rationalise the workforce, and then embark on clinical engagement.

“My guess is that many CEOs might argue that engaging clinicians early will slow them down and reduce their degree of freedom. Some of them certainly feel it is a matter of months before the regulator comes down on them and they do not have time.”

It is a big ask. For one thing, doctors practising in the NHS are not engaged financially, or at least not in the same way as in the US. Dr Bohmer relates an anecdote to make the point.

“I was at a quality forum of UCL Partners and although there were two hours of debate and analysis among professionals about quality programmes and quality improvement approaches, not once were the words ‘growth’ and ‘efficiency’ mentioned. The business concepts that you would hear in the same conversation in the US never appeared.”

Less anecdote, more analysis

So the next big question is how to engage clinical leaders at a time of financial crisis? “That’s where I want to go with my research,” says Dr Bohmer. “The ‘how’ of doing this.”

Measurement and data collection are likely to be very important, he says. “We need less anecdote and more thoughtful analysis. I know criticising the data is a professional sport but, having said that, professionals are fascinated by data. An important component of the ‘how’ will be conversations about how to get the data the best we possibly can.”

We also need to look at how we develop a culture of learning, which may come from peer-to-peer discussion of data, he adds.

Engaging clinicians so redesign of services to increase value (ie quality and cost) becomes the norm requires supportive policy and regulatory frameworks too.

“The interaction between national policy and how good organisations operate is not something I fully understand,” says Dr Bohmer. “Policy has an important role in creating an environment in which managers can do their very best work, but do policy makers understand what a good organisation looks like? I don’t know.”

Nor is he clear on the extent to which regulators understand what a good organisation looks like. Here in the NHS, the quality, innovation, productivity and prevention programme is one of the main planks of the policy agenda. It may be how we are going to save £20bn or more in five years and it may be a good idea – but is it ultimately doomed?

Dr Bohmer is careful in his response. “If you take a look at organisations that have seriously addressed the questions of process redesign, process control and microsystem design, they have realised substantial improvements,” he says.

“So the first answer is we have not really understood the full potential for doing this elsewhere and one might be quite optimistic about our ability to do so. But the counter-argument is that in the face of the demographic changes and, in particular the growth in frail older people, the potential future costs of the health service are much worse than we think they will be and all the operational efficiency in the world will not be enough to address these potential future costs. This is a really legitimate concern.”

Dr Bohmer foresees years of uncertainty ahead. “The way through this is to focus on developing credible, effective organisations where clinicians are engaged in the leadership,” he says. “Effective management realises better outcomes for patients – and by that I mean clinical management. My real challenge is to help figure out how to help managers through these challenging times and help clinical and non-clinical leaders to develop and run better organisations.”

Find out more

The King’s Fund will launch its final report on the review of leadership in the NHS at a summit on 23 May in London. For more information visit the King’s Fund events page.