Do external consultants working in NHS organisations really deliver the goods? Birmingham University's Jonathan Shapiro argues that they may know how to diagnose problems, but cultural signposts pass them by

Do external consultants working in NHS organisations really deliver the goods? Birmingham University's Jonathan Shapiro argues that they may know how to diagnose problems, but cultural signposts pass them by

It has become an aphorism that 1.3 million people work for the NHS and that it is the fifth largest employer in the world. Over two thirds of its total costs lie in salaries and its largely professional workforce is arranged into innumerable tribal groups: clinical, managerial, technical, administrative and so on.

Furthermore, it seems to be in a constant state of flux as its government masters try to achieve efficiency and increasing effectiveness in timescales that reflect political needs rather than human and organisational ones.

This has meant that for nearly 60 years the service has been evolving and developing but, like the rest of our egalitarian public sector, it has focused on the delivery of its short-term goals at the expense of effective strategic planning. The general perception is that strategic direction comes from the centre, and not only is there little point in preparing a route across the stormy oceans if the admiral keeps changing the destination but also that doing so may actually bring the admiral's wrath down on any poor seaman who tries.

Whether as part of this disempowerment or as an additional factor, an important extra dimension to our traditional lack of long-term thinking has been that public and political attention tends to focus on the 'here and now' rather than the future, so that developments centring on 10 years hence generally hold lower priority than those looking at the urgency of present demands.

But, in theory at least, some of this is changing; the NHS is being developed as 'a game of two halves', with egalitarian public sector commissioners planning services for entire populations in one half and, in the other, contracts with free-standing providers that need to look after their own interests.

One of the more obvious impacts of any sort of market economy is that both procurers and providers are responsible for their own fates: if we overspend our domestic housekeeping there is no external 'parent' to bail us out, just as if the local shop always sells its goods at a loss it will have to deal with the consequences. The days are meant to be over when wicked acute hospitals were bailed out for their inefficiency with money accrued by well behaved community providers.

Tricky problem

This transition has highlighted a tricky problem: how to change a set of organisations and people who have been actively discouraged from determining their own destinies and whose learned helplessness has to be entirely reversed.

This problem appears to have been addressed in two ways: by bringing in senior managers and non-executive directors from the private sector, and by using external consultants.

The first of these offers the opportunity to learn from others who have the entrepreneurial skills needed to survive and thrive in a commercial world, but assumes that 60 years of central control can be unlearned overnight. It is bringing into the service people who have an entirely different mindset (which may well be the one the 'new NHS' is seeking) but who do not necessarily have the skills required to make the transition from the old to the new.

Similarly, the models of consultancy being used focus on the content of the system but not on what really makes it tick. The large consultancy houses that have been brought in have looked at finances, and they may even have looked at clinical issues, but they have done it in a 'context-free' way. To plan a transformational journey of the magnitude that is implied by the current round of reforms requires an enormous cultural shift, and most of the current models of change management take little if any account of where we are, why and how we got here, and what the obstacles are that we need to overcome in order to move on.

Having the most erudite financial whizz kid informing a trust that its doctors have to behave differently is no help unless those in the trust know how to make them behave differently; just as explaining that the organisation has to be more businesslike will not in itself help to make that happen.

The external help that is required to facilitate change can be summarised as objectivity, capacity, and capability. The first is intrinsic in any effective and ethical consultancy work: external consultants may well 'use your watch to tell you the time', but their distance and lack of vested interest usually makes that a useful thing to do. The external consultant's legitimate role may be no more than to feed back to the client what is really happening in their organisation ? to reflect what the insiders cannot see or may not be prepared to say.

If an insider criticises their organisation there may be unfavourable consequences for them personally. If consultants criticise, the worst that can happen is that they won't be hired by that client again. Moreover, if they are recognised for their honesty and plain speaking, they may gain a reputation that actually encourages clients to seek their views, almost as a benchmark of objectivity.

The case for capacity is obvious: if you double the work of those in an organisation without doubling their capacity, something will give. Either the old work or the new work will not get done, or neither will get done properly. If staff are especially enthused about any proposed changes, they may be prepared to work much harder for a short while, but the NHS is not known for its powers of enthusing nor for showing its appreciation of the work staff have done. So extra capacity may well be required at times of significant change, even if only on an interim basis.

Capability is different since recognising one's own lack of knowledge and skills is much harder than recognising one's lack of capacity. Organisations may well benefit from some external help in moving from the state of 'unconscious incompetence' to that of 'conscious incompetence', and once that has been acknowledged, they may also appreciate some interim support in those areas where they have yet to develop their expertise.

A very different task

So, for example, many primary care trusts are discovering that commissioning is a very different (and more complex) task than they had envisaged, and they may well benefit from both extra capacity and capability in this area: capacity to learn the new job while maintaining the old and the capability to carry out the new job, and even teach to the 'in house' team until they are up and running.

The current models of consultancy may do the first of these three tasks, but they generally do not adequately address the second and third. Their world view reflects that of their parent organisation, which is usually financial. They lack contextual knowledge and understanding of the service; they lack the transformational skills necessary to move cultures; and they also lack the ownership and engagement of their 'clients', a word in inverted commas because that is yet another of their problems: the turnaround team's customer is rarely the consumer of its services.

External help may well be of assistance to the health service in times of change, but to succeed it must have a degree of ownership by the consumer, it must be appropriate to that consumer's needs (that is, finances when it's a financial problem, but cultural change when that is the issue) and it must provide the right mix of capacity and capability.

Above all, it must offer sustainability: the transfer of both capacity and capability to the consumer organisation so that the culture of organisational dependence that we are so desperately trying to outgrow does not merely move from dependency on the state to dependency on external consultants.

Once the 'fat four' can fulfil all those criteria, they can compete for the business. Until then, it is high time some other, more appropriate agencies entered the fray.

Professor Jonathan Shapiro is a senior fellow at Birmingham University's Health Services Management Centre.