Published: 22/08/2002, Volume II2, No. 5819 Page 26 27
Constant structural change demoralises staff and can never deliver modern services without serious attention to patients' experience. Steve Killigrew reflects
Modernisation Agency and the various healthcare collaboratives that have emerged in the wake of the modernisation agenda tend to favour patient process redesign as the method most likely to reduce the zone of delusion and improve the service to patients. Redesign focuses on the patient journey as the core process in health and social care. This represents a radical alternative to the present culture of reorganisation without improvement, The government's modernisation agenda aims to improve the speed and quality of patients' journeys through the NHS landscape.
1And the scenery is constantly changing. In April 2002, the therapeutic landscape shifted yet again, both organisationally and geographically, with the formation of strategic health authorities. These were the latest examples of the continued fascination with structural and organisational change in the NHS. The emergence of new primary care trusts, community care trusts, mental health trusts and huge hospital trusts is a clear indication that the rate of organisational change is accelerating at a time when many are questioning the lack of demonstrable improvements for patients.
This enchantment with structural and functional change has been described as creating a 'zone of delusion' between the NHS and the healthcare that is required by people and communities in the 21st century.
2This delusion is not only a result of a healthcare system being out of cash but one that is also out of date and out of touch. The government is attempting to address these issues through increased funding and its modernisation agenda.
Spending more money is relatively easy to demonstrate, but how can modernisation fashion in-roads into the claims of the service being antiquated and remote? Success will not come from applying more of the same - namely changing the structure first then fitting the patient journey to it.
It is in becoming more up-to-date and in touch with people's needs that modernisation's success or failure truly depends.
Experience teaches that there is no such thing as the perfect methodology, only the most evolved and appropriate one. The Nuffield Institute, the NHS replacing it, potentially, with one of improvement without re-organisation.
Modernisation is about replacing the precedence culture ('We have always done it this way') with an intelligence culture ('What have we learned and how can we improve?').
Open and honest dialogue is the starting point for redesigning care. This necessary work has begun, but it is patchy and is proving difficult given the wide range of organisations and professional cultures employed in the care sectors. One fundamental principle that must unite all care organisations is the ambition to deliver the best possible services to the people who use them. At present, the most evidence-based method for improving the quality of care is process redesign.
By focusing primarily on the patient journey, process redesign promotes inter-departmental and cross-sector working in a way that is often difficult to initiate and sustain using other means. The process incorporates core elements in the modernisation agenda: patient-centred care, staff involvement, new roles and therapeutic alliances and greater input and involvement from service users.
Process redesign can help care organisations to become the learning organisations that are required to respond to ever-changing care needs.
Redesign should follow the patient journey from beginning to end. There is no benefit for patients in improving the ambulance or appointment systems if this means that patients spend more time sitting in waiting rooms. The whole patient journey needs to be followed and the delays and duplications analysed.
A whole-system approach includes moving away from thinking about care organisations as machines - good at command and control, poor at innovation and learning - towards seeing them as living systems - good at adapting, evolving and dealing with complexity.
Whole-system working takes us away from restructuring the parts to redesigning core processes in order to implement improvements. The whole-system approach coupled with redesign offers an appropriate framework for implementing improvements.
But there is no such thing as the perfect methodology, so what are the risks?
The risks are mostly people, time and resources.
Perhaps the most important and least acknowledged of these risks is the people factor.
One of the fundamental contradictions of today's NHS is the defence of constant reorganisations and performance targets in the name of organisational health.Having set numerous targets and made repeated restructurings, care organisations discover that the only reserve of improved efficiency is more intense and wide-ranging effort by staff.
Organisations then discover that those employees are the survivors whose commitment has been weakened by previous mismanaged transitions.
This is an important factor at the heart of the recent low levels of staff morale, recruitment and retention across the NHS.Managing transitions means bringing people with you - patients and staff - in redesigning the service.Helping staff and patients to cope and live through change is greatly enhanced by actively encouraging their involvement in every stage of redesign. Unless the people factor is acknowledged and managed as a critical risk factor in redesign projects, real and sustainable change is unlikely to occur.
Reorganisation, re-engineering or redesign, whatever you call it, change is still change and can be stressful. People are not cogs in the machine, but individuals with lives to lead and families to support.Most significantly, they are capable of seeing through superficial or dubious changes.
Organisations will not change unless the people in them do.Gaining commitment to improve is a battle for hearts and minds and not merely a matter of management directives, mission statements or a repeated reshuffling of organisational structure.
Staff in care organisations may have doubts if they see change projects being lead by just one particular sector. For example, people from primary or social care organisations may be dubious about change lead by a large university hospital trust, or vice versa.
Conflict can also arise between professional groups within the same organisation. In a single organisation structure, power and influence may be viewed as a given. This is unlikely in the new cross-sector initiatives where many organisations are involved.
New ways of working are needed.The traditional approach of committee meetings has become uninspiring and fatigued. Problems can become drawn out rather than resolved.We need facilitation skills that bring people together to form new systems for improving patient journeys and nurturing innovations.
At this critical stage in the modernisation project, there is a significant risk that many organisations may not have developed the necessary level of trust and mutual confidence to engage fully.
These fears need to be explored in an open and honest exchange of views between stakeholders.
Redesign also requires robustness, transparency and neutrality. Perhaps, for these reasons, redesigns may be best facilitated by organisations clearly viewed by all stakeholders as coming entirely from outside health or social care sectors.
Key stages in process redesign
Stage 1 Involves building foundations, clarifying objectives and strategic project planning.
Some key questions:
What are the likely benefits?
Who must be involved?
What could go wrong?
Stage 2 An analysis of the current situation.
Some key questions:
Where do our patients come from and go to?
Where are the problems, issues, delays, duplications and challenges?
How can we involve patients and staff effectively?
How many steps in the journey do not add value for the patient?
Stage 3 The redesign concept.
Some key questions:
What would an improved service be like for patients?
What is the gold standard?
What might our service be like a decade from now?
What is the simplest patient journey?
Stage 4 Action planning; identify projects and teams working towards the redesign.
Some key questions:
What needs doing first?
What are the key pilot projects?
Who is doing what?
How can we share the learning?
Stage 5 Implementation and monitoring.
Some key questions:
How do we know that a change is an improvement?
Where is there resistance?
What have we learned from piloting so we can do it better tomorrow?
The success of the government's modernisation agenda in the NHS will depend on services being considered from the point of view of the patient journeying through the system.
Restructuring organisations does not, on its own, improve care.
Services cannot be improved without the involvement of staff, who may well be demoralised by the frequent organisational upheavals.
1The New NHS: modern, dependable. The Stationary Office, 1997.
2Warner M. Re-designing health services; reducing the zone of delusion. Nuffield Trust, 1997.
3Paton RA, McCalman J.
Change management - a guide to effective implementation. Sage, 2000.
4Paidosh L et al. Customercentred redesign. A requisite for creating effective improvement.Michigan Health and Hospitals magazine. July/August 2000 5Pratt J, Gordon P, Plamping D.Working whole systems. Putting theory into practice in organisations.
King's Fund, 1999.
Steve Killigrew is a consultant project manager.