Ensuring commissioners have the necessary skills to manage service change is an investment we cannot delay, argues Ciarán Devane

Ciaran Devane

As an engineer known for saying that the NHS needs less science and more engineering, Philly Hare’s blog titled “More Engineering, Less Architecture” was always going to get my attention.

Philly works at the Joseph Rowntree Foundation specialising in the ageing society. It proved a good read.

Lost our way  

Her point is that structures and systems are less important than changing how we all relate to each other. Absolutely, I say; well almost.

‘Good change projects start at the end and are managed by critical success factors, not activities’

My own point is that we are getting greater insight into specific “unit operations” in a health pathway but have neglected the “process” – the pathway itself, the interaction between interventions, the feedback loops and the unintended consequences.

A particular tragedy is when we aspire to transform care we proceed by tinkering with the bits, always improving services that are fundamentally unable to cope clinically or financially in the world we are heading into.

We start in absolutely the wrong place: today.

Good change projects do two things well. They start at the end and they are managed by critical success factors, not activities.

Good commissioning

Take commissioning. The goal of good commissioning is to develop and provide services based on current and future needs of the local population in all its diversity. And no one commissioner will do that.

‘For commissioners to be successful they will need the skills of change project management’

Clinical commissioning groups, NHS England and the local authority all have their role. So logically, if we start at the end then we should ignore the architecture, pool our interests and work with the provider base to develop the right answer.

This is what the Staffordshire Transforming Cancer and End of Life Care Programme is trying to do.

Two 10 year contracts have been announced which expect the provider base to work together to deliver the best possible outcomes for the available funds.

The prime providers that will ultimately manage all the cancer and end of life care will build in the themes which are needed to deliver high quality, patient centred, cost effective care.

So expect to see prevention, coordination, self-management, “holistic” support and co-created health designed in. And not only are the themes of the end game fairly clear, many of the components of the pathway are also clear with evidence supporting their rollout.

Across the border

A similar logic has been applied in Scotland where cancer is being increasingly viewed as a condition to be managed beyond the confines of acute care.

In Glasgow in particular, cancer is seen as an issue for public health, welfare, medicine and home care. It is seen as a condition that benefits from existing community structures.

Those diagnosed with cancer in Glasgow get a letter offering a full holistic assessment at a service of their choice, and all agencies are lined up to meet the needs that are identified.

The impact of integrated care in the city is clear from the hundreds of families who avoided eviction and associated costs to the local authority, the treatment plans adhered to and in better outcomes.

Managing risks

So what about critical success factors? An oft repeated, if spurious, fact attributed to a well known management consulting firm is that over 60 per cent of change projects fail.

What is clear is that good projects manage critical success factors – or to put in another way, the exact opposite of a risk assessment, although you need that too.

‘It is an investment of money and time, and an investment we cannot afford to delay’

A risk register identifies a range of things from the unsurprising – suppliers may miss deadlines – to the clever but irrelevant – the sky may fall in.

A critical success factors register will say: if this project is to fly, a few things must work really well. The public must buy in, inpatient stays must reduce and the outcomes must be better.

So the project is structured, resourced and managed not only behind the IT, the clinical service specification or the cost reduction, but also behind the outcomes, the communications or stakeholder engagement. These are resourced properly and with the same degree of expertise as the IT, clinical or cost reduction work.

For commissioners to be successful they will need the skills of change project management. As I am in the habit of saying, we cannot magically expect people – no matter how talented they are – to spontaneously acquire them.

It is an investment of money but also of time. It is also an investment we cannot afford to delay.

Ciarán Devane is chief executive of Macmillan Cancer Support