Why Getting it Right First Time is easier said than done

Getting It Right First Time is one of those rare initiatives that flies beneath the radar but may well have real potential – perhaps because it flies beneath the radar.

GIRFT essentially consists of providing consultants and other clinicians with all of their unit’s data – their clinical, managerial, financial and litigation performance – all in one place, and often benchmarked, in an easily understood slide pack; and then having an undeniably senior figure in their own speciality discuss it with them. With at least one follow-up visit a year or so later.

This so far has attracted many fewer headlines than the vanguards, the sustainability and transformation plans, or even Right Care, its commissioning equivalent, let alone the overall financial position of both the NHS and social care. At its best, however, it has the potential to contribute to all of those while adding real value in its own right.

On the small number of visits to orthopaedic and vascular units that the King’s Fund joined as a fly-on-the-wall observer, what was striking was that clinicians (and in the best places that included not just consultants but nurses, physiotherapists, radiographers and others) not only engaged with the data but seemed energised to act on evidence which showed that getting it right first time not only raised quality but, often, saved money.

Nowhere did we witness huge resistance, or the view that this was a waste of time. And in at least some places, action did indeed follow, if not always on every aspect of it.

So what is GIRFT’s key strength?

The short answer is that it is clinically led – clinicians, not managers or inspectors, talking directly to clinicians. And led by the same tiny team that can therefore make consistent judgements and relay anecdotal as well as hard evidence. That is a contrast, for example, with the CQC which cannot possibly provide the same team for all of its whole hospitals inspections.

So what are GIRFT’s biggest challenges?

Within specialisms that the King’s Fund saw in action – orthopaedics and vascular – there were clearly things that clinicians themselves could do to improve their service.

They were, in the main, keen to do that. But a fair number also required management action within the hospital. And some of the more significant changes also required a commissioning response. For example, in the case of vascular, having a top class diabetic service out in the community to reduce the need for amputations. Or in the case of orthopaedics, persuading CCGs to stop commissioning pointless arthroscopies from private providers.

On the KF visits, the commissioners had yet to be engaged. Not surprising, as this was early days. But management interest within the hospital varied hugely, from one visit with the most junior possible manager there to another – a meeting of 40 people – at which the chief operating officer was present, and another with the chief executive there.

So to succeed at scale, GIRFT needs not just the clinician engagement it appears to generate, but managerial, and then commissioning involvement – which includes how to align it to Right Care.

But behind that are two profounder challenges.

First, the other 30-odd specialisms that are now to be covered need the same top quality clinician leadership that orthopaedics and vascular have enjoyed.

And second, there is a suspicion on all sides that the units that engage least with GIRFT are those that most need it. But the more this becomes a managerial requirement (“you have to act on this because your results are poor”), and the less it continues to be “We are a bunch of clinicians here to help”, the less effective it may become.

Which leaves the question of how do you use a programme like this to make a difference in the places that, for whatever reason, good or bad, do not want to know?

Nick Timmins is senior fellow, policy, at the King’s Fund.