conference focus :

NHS plan targets cannot be delivered unless staff start breaking all the rules, according to the redesign double act of Professor Helen Bevan from the National Patients Access Team and Paul Plsek, author and international consultant on innovation and improvement.

Their masterclass emphasised the need for the NHS to take a 'second-order change perspective' if reform is to be successful.

Tackling the plan targets could only be done from a second-order approach to change - getting rid of the old rulebook and experimenting with new ways of doing things and redesigning the whole system. 'What we see is a lot of first-order change where, typically, people say they need less or more of something - more doctors, more equipment, more resources, ' Professor Bevan said. 'We need second-order change where we stand back and look at the whole system.'

Such an approach was counterintuitive to a service that 'knows and loves its SAFFs (strategic and financial frameworks)', she said - the classic first-order approach to planning and organisation that tinkered at the margins, rather than focusing on the mainstream of services.

A case study in redesign was illustrated by Hugh Rodgers, director of elective services at West Middlesex Hospital trust and a clinical lead in the Cancer Services Collaborative.

'We will not make any shift in reaching targets unless we have radical redesign - that has to be the basis of our strategy to deliver the plan', he said. He described how the trust had abandoned the old rules in providing breast cancer and prostate cancer services.

Out went the referral letter system, replaced by phoned and faxed booked appointments; separate teams were replaced by one integrated team with nurse-led clinics; and instead of a service where capacity determined waiting times, demand was measured and the capacity set up to deal with it.

Waiting times of up to 18 weeks for patients suspected of having cancer fell to a maximum of seven weeks from referral to treatment.

Paul Plsek's message was that even the most complex of systems had simple rules and by questioning them and trying alternatives great change could be achieved: 'Think second-order change, think simple rules as the starting point for making change happen.'