What planet are we on?

Impressive initiatives, middling performance. This was a top line finding in the Organisation for Economic Co-operation and Development review of the UK healthcare system published earlier this year. The puzzle was, why?

It is not because we invest too little in healthcare. Recent OECD analysis shows we are bang on the EU average at 9.9 per cent of GDP spend (albeit with lower comparative per capita spend than some nations we like to compare ourselves with). Or that we are short of ideas for improvement. But it could be related to the way we have approached progress, which needs a fundamental and practical reboot.

Consider two worlds. World one is made up of bounded interventions that we can think up, design, implement, evaluate, scrap if they don’t work or move on to the next. In a system like the NHS many of these will be high profile and national. And if linked to the government of the day, the aim will be to have a national suite of interventions which can show progress in the short term.

In this world, the road ahead will be mapped out by initiatives like paving stones to the shortish horizon ahead, with each having a measurable beginning, middle and end. With luck, the paving stones interlock into a proper road which people can see down. Let’s call this world “planet intervention”.

Minimising risks

By contrast, world two is “planet context”. Less like a path of static paving stones, more like the weather. Everywhere, unpredictable, moves in all directions, at different speeds, with changeable elements. The weather can cause massive disruption (flooding), delay and hassle (wrong kind of snow) or be favourable. Crucially, it has no beginning or end, it just is. Longer term planning is needed to make the most of the elements, predict and minimise disruptive risks.

On planet intervention, people ask “does it work?”

On planet context they ask “what conditions are favourable to making progress?”.

On planet intervention it is usual to think up a solution and drive it into existence.

On planet context, solutions are discovered or co-designed and tested.

On planet intervention, noise is ignored and failure inconvenient, but on planet context both are useful to learn from and course correct.

On planet intervention, people like investing in big ticket new machines, buildings, tech, and guidance. On planet context, it’s people, skills, culture and dialogue. On planet intervention, people are seen as leaders or more often resisters; on planet context as team-oriented managers.

Spreading improvement at scale is a challenge; and interventions often fizzle out, in part because it takes effort to achieve them despite the system

OK, the caricature is too simple – both worlds are needed, and both interact in complex ways. But the prevailing approach in health policy, at least nationally, looks more like “world one”. And it’s there locally too, with multiple interventions being tried around the country, whether clinically focused – say improving sepsis care – or managerially focused, such as implementing complex new models, or even STPs.

There are plenty of good examples of innovation and progress here, not least as we see at the Health Foundation from our grant portfolio over 15 years. And of course the Academy of Fabulous Stuff. And more.

If there is a strategy for “planet context” it appears flapping in the wind, underpowered and over there

But two big issues have long been noticed: spreading improvement at scale is a challenge, and interventions often fizzle out, in part because it takes effort to achieve them despite the system. Assume “world one” is the whole truth, test it to destruction given the financial squeeze, attempt to “roll out”, and lack of spread and fizzle-out will be the inconvenient result and a brake on progress. Why? Context, which might be a more active ingredient for progress than high octane Stakhanovite “interventions”. Look up from laying the paving stones, and you’ll see there’s a big storm slowing you down.

Need to be convinced? Take a national high priority example – improving patient flow through and across various healthcare settings. Look at current experience, as outlined in our report this week The Challenge and Potential of Whole System Flow.

Enter “World two”. What might help? Supporting, skilling up, motivating, trusting people – the workforce and patients – to make change, every day. Sure, test those interventions, but create them to develop and respect the context too. We’ve heard this before, but it is not developed, hard headed or connecting enough to “planet intervention” which is the hard currency of the moment. If there is a strategy for “planet context” it appears flapping in the wind, underpowered and over there.

There is some progress at national level. The vanguard programme has modelled a more adaptive, iterative approach to change, and is now considering how to spread new care models in a way that pays attention to the active ingredients for improvement.

Retain, motivate, skill

Not a simple intervention blueprint to implement, but giving space to teams to design, test, measure and refine according to local conditions. This month’s publication Developing People Improving Care from NHS Improvement is exactly in the right terrain: building improvement skills; developing current and future leaders; and managing talent across the NHS, and ways to track them.

The developing DH workforce strategy must feature here too – not just getting the right numbers of staff planned, but in helping retain, motivate and skill up staff. This month’s National Quality Board’s publication Shared Commitment to Quality to support the NHS Five Year Forward View also clocks this terrain. Tracking improvement capacity and creating space for ideas to be shared should be the balancing zeitgeist.

While the intent may be there in conception, these national developments are mainly documents, read by few, seemingly remote from the front line and incidental, nice-to-haves to the main agenda. The latter is a costly world view. As we glimpse the limits of “planet intervention” we need as much thinking on “context”, which now needs to be tested to destruction up and down the NHS. How? More on this to follow.

Jennifer Dixon is chief executive of the Health Foundation