Stephen Eames on quality vs cost

The patients who use our services would, I suggest, expect 90 per cent of our time as service leaders, managers and health service commissioners to be spent on delivering things. So would most of our staff. So, for me, execution is strategy and no more so than in the current climate, when there is no time to squander on unproductive meetings, ineffective processes or wasteful activities.

If you invest in staff, and they commit to invest in you and the organisation, then your endeavours are more likely to be successful

Our trust has just set off on our Towards 2014 programme, which aims to deliver service and quality improvements combined with reducing our operating costs by a minimum of £30m (roughly 10 per cent of our total budget) over the next 18 months. These plans include reducing the unit costs of our services by further streamlining bed, theatre, diagnostic and outpatient usage, shifting services closer to home and workforce skill mix and productivity programmes.

A personal lesson for me that permeates this and is drawn from bitter experience, when I was more self-centred as a leader than I hope I am today, is the importance and value of people. If you invest in staff, and they commit to invest in you and the organisation, then your endeavours are more likely to be successful. A philosophy, if I may say, which is in stark contrast to the talk of “nuclear options” adopted by regulators recently.

A major building block of our Towards 2014 programme is to ensure the required hard graft of the lean years is complemented by making sure the soft side is not ignored.

In this context there are some prevailing views and mindsets we need to change. Often the prime one is that there has to be a trade-off between the quality of services and the cost of providing them. Another is to create among all staff a mindshift that deals with the belief that going leaner does not have to mean cutting to the bone.

During our discussions many of our “shop floor” leaders energetically identified wasteful operational and bureaucratic processes, from excess paperwork to fallow clinical time. All must be addressed.

It is also essential to tackle head-on the underlying anxieties that the current climate inevitably engenders: will I have a job? We are making it clear that by 2014 we expect our workforce to be smaller but that we want to tackle this challenge in the smartest ways possible.

Ideas and input from the floor included suggestions about reducing sickness levels, creating greater levels of flexibility and productivity, and incentives to cut out waste and make poor usage and practice transparent.

I know there is an inherent cynicism in any organisation about initiatives like Towards 2014, not least because persuading people to go on a journey where the last stop could be removal or reassignment is not easy. So the emphasis must also be on relentlessly seeking improvements that make a difference for patients, while trying to create opportunities for growth and to keep jobs rewarding and meaningful.

There were some clear and blunt messages for me in these conversations. Staff are expecting that internal bureaucracy will be tackled, that room will be given to greater autonomy and that they will be given the chance to innovate and develop new skills. When asked what was in the way of making swift progress, they came up with recurring themes about our finance, training and HR policies and the inability of our communications and information management and technology systems to reach out as effectively as they might to frontline staff.

Strong views were expressed about the need to tackle people and systems issues that frustrate and block change. Bringing these problems to the surface and dealing with them is one of our biggest challenges because often there is a skill gap, fixed professional boundaries or entrenched mindsets. In their article on lean systems Nina Bhatia and John Drew argued that many organisations keep their “water levels” high and only deal with problems when they break the surface. The underlying root causes are masked and, rather than resolving them, something is added to the system to compensate. I suspect many of us recognise this and can point to instances in our own organisations. We will have to move from bandaging some problems and to finally solving them.

So, if execution is strategy what should we focus on? Our chief operating officer likes to refer to this challenge as “the three card trick”, that is, better services to patients provided at less cost and at a higher quality. Our Towards 2014 programme is designed therefore to address inflexibility, variation and waste, while keeping a razor sharp focus on ensuring that what we do adds value for our patients and public. We also want to create an organisation-wide conversation that changes the flow and nature of the information we use, and to tap much more effectively into the energy generated by the 5,000 people that make our hospitals tick. Most of all we want this to be action oriented and to create an atmosphere that makes all staff members ask the question: “What can I do to make a difference today?”