Up and atom

Published: 12/02/2004, Volume II4, No. Page 5892 34 35

Everyone involved in failing NHS organisations must play a part in its recovery, but outsiders too often fail to understand the complexity of the problems. Turnaround expert Jan Filochowski concludes his series by arguing that the solution may lie within the 'organisational DNA'

Those outside an organisation can view turnaround as much easier than it is. Inadequate time is allowed and there is little understanding of the cultural meltdown that has occurred. Not surprisingly, this attitude is most often found in people who have not experienced the complexities of large provider organisations. The separation of providers and commissioners and of monitors and deliverers reinforces these differences. The rhetoric of support is often accompanied by an unremitting, unyielding demand for improvements.

Those who make such strong demands need to consider what the alternative is.We are one NHS but many of our behaviours towards failing organisations are those of separate organisations with little mutual loyalty and responsibility. Organisations next door to failure deny it has any connection with them or take any responsibility for it, when it does and they should.

Equity is fundamental to the NHS. It means equity of access, good treatment and outcome and is what lies behind the choice initiative. Other interpretations of equity often face failing organisations, namely equity of allocation and suffering. Implicitly, and often explicitly, a failing organisation is told: 'You are unable to provide the same level of service as other parts of the NHS but you have had your fair share so you and your patients will have to make do.Giving more would be rewarding failure.'

The extension of star-ratings to primary care trusts and strategic health authorities has been a good idea.

There is now a sense of 'we are in this together; your failure is mine so let's ensure our success'. Funders have historically been too protected from responsibility for failure. Failure is rarely caused by lack of funding, but it can contribute. I have seen funding denied to recovering organisations because funders were not fully convinced it would be used properly, even though the alternatives would cost more, provide less, and leave more failure. An independent mechanism to validate need may be the answer.

The NHS loves plans. The appetite for plans from failing organisations increases in inverse proportion to ability to construct them credibly. The result is that the organisation does even less, presents proposals it does not believe in, and (because bureaucracy is not stupid) which are not believed. Slow progress can be turned into paralysis. Recovery plans need to be internally constructed and owned, along with practical support mechanisms so that staff can deal with the real problems and look ahead to find the solutions.

As star-ratings measure performance retrospectively the failure affects the rating a year, or even two, after the disaster. This further demoralises staff who may have moved heaven and earth to improve performance. Due to its performance in April-June 2002, Royal United Hospital Bath trust received a zero-star rating in July 2003 - even though it had moved from being the worst in the country to achieving its year-end targets.

We need a measure to assess the degree of change over the previous year. Star-ratings are slow to pick up an organisation that is deteriorating and starting to fail. A measure of whether the situation is getting better or worse would signal a problem much more clearly.

External scrutiny

An objective view may be needed to restore public confidence. To date, reviews of failing organisations have been variable. The best have a wide remit and a broad view, based on substantial knowledge. The most comprehensive was the Bristol inquiry, but its timescale meant it could not impact on the running of the organisation when it was most needed. The Tinston review at RUH Bath trust took a broad, comprehensive view and picked out key matters for moving forward.

Narrow reviews can sometimes be what is needed. But if a specific review of a major problem is taken as an analysis of a whole organisation's failure, it will mislead and direct attention away from underlying causes.

Full inquiry or not, having someone take the temperature of a 'failing' organisation to assess whether it is making progress, stuck or going backwards can be useful. It is quick, unbureaucratic and can identify where key problems remain. I hope the Commission for Healthcare Audit and Inspection develops this capacity; it will need senior, respected and experienced people.

Failing organisations typically get and deserve an awful press. Although many staff believe they are victims of an insensitive media only interested in failure, my experience does not bear this out. The local media wants to do positive coverage of healthcare. If it is shown something positive, and is honestly told what is wrong, it reports fairly. National media often takes its cue from local media.

There will be periods when senior posts are vacant. Even in a reasonably functioning organisation, this can slow momentum. In a failing organisation, the risks are much greater.

A decision must be made to bring in a positive, authoritative management regime.While the long-term future is sorted out, problems can be tackled straight away. It is no good bringing someone in and saying: 'Get on and solve things.' Clear, realistic goals are needed and recognition that some things may take time and need external support.

A tell-tale sign of organisations at risk of failure is inattention to significant detail. I have repeatedly come across organisations facing serious problems that were avoidable if they had mastered the right detail at the right time. This is particularly true of some of the more complex aspects of star-ratings, where organisations have lost stars they could easily have kept.

The criticism often made of star-ratings, and the emphasis on managerial failure, is that it fails to take account of clinical quality. RUH Bath trust received the worst overall star-rating nationally, while Dr Foster's Good Hospital Guide showed that it was one of the country's safest hospitals. In contrast, the Bristol inquiry showed the importance of effective managerial mechanisms and controls to ensure safe practice.

At RUH Bath and Medway trusts, clinicians were demoralised despite being good at what they did. The organisation to which they had committed themselves was being pilloried, and they took it personally.

Disempowered, demoralised clinical staff hide away and get on with what is within their control. They will not participate, highlight problems or seek wider solutions.

A failing organisation's governance will almost certainly be failing. And its clinical governance will have been neglected because the organisation will not be cohesive, determined and committed. It is likely to lack the will and wherewithal to deal with the problems that a good clinical governance system tackles: safety, procedures, and ensuring competence.

Two poisitives I underestimated First, I now strongly believe that people in every large NHS organisation are broadly of the same high quality.

The failure is the managerial context, not the people. To put it right, the context needs to change, not the people.

The second relates to the organisation itself.

Management thinker Peter Drucker has described hospitals as the most complex managed organisations in the world.Within them is stored huge amounts of experience and understanding of healthcare processes.

This is best thought of as 'organisational DNA'.

When things go wrong, a common mistake is to assume there is a need for complete reinvention of processes and ways of doing things. This is an error - 99 per cent of the understanding required to get the right things working properly is already in the organisation's genes. The trick is to get it out. But it is far easier and far more effective than starting from scratch. l Filochowski cv Jan Filochowski was the chief executive credited with the improvement at Medway trust, moving it from no stars to two.

In 2002 he was seconded to the troubled Royal United Hospital Bath trust, then dubbed 'the worst hospital in the country'by ministers.

By March 2003, performance had improved dramatically and waitinglist targets had been achieved.

Last year, he took up his current role as roving turnaround chief executive across the South East.

This is the final article in Jan Filochowski's five-part series. If you would like full set of the original, longer versions of these articles, e-mail jan. filochowski@nhs. net