My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »


Why is innovation and its universal application so important? Health care is a very dynamic service. For the NHS to maintain and develop support it needs to be able to demonstrate that it not only gets hold of the very newest ideas but that those ideas are promulgated throughout the system as quickly as possible.

This is a matter of saving lives and relieving pain and distress.

At the moment innovation in the NHS is patchy. In some parts of the you will find the latest idea that will relieve distress but it will be provided alongside something that was out of date a few years ago, and that in turn will be provided alongside something that was out of date many years ago. I have typified this as a geology of forms of provision with one overlaid on another overlaid on another etc.

The failure to drive out the old with a tough and universal application of the new causes real problems for public services. It does so because the model that other industries and services have – one where the consumer uses their money to drive change – looks to be very successful. The public look to the way in which innovations in communication have changed their lives and have changed the lives of most of the population – and they ask why can’t that happen in public services.

The enemies of the NHS can then point out that where individuals buy goods and services with money from their own pocket they can drive change throughout a service. Within this model of change what happens is that new ways of doing things become the norm because the old says of doing things are wiped out by consumer preference. The very big mobile phones of 15 years ago are no longer being made. The numbers of people who use the internet to search for insurance bargains has changed the industry works.

Consumer preference, plus consumers having the financial power to enact that preference, has driven these changes not in a few little places but throughout the industry or service.

People want to know why their hairdresser reminds them of their appointment but their hospital doesn’t.

If the friends of the NHS do not have an answer to this issue of speedy diffusion of improvement, then the enemies of the NHS will demand that the cash driving consumer preference as a proven method of improvement becomes the norm in health care.

There is an answer from the NHS of the past as to how innovation and improvement is spread. That is through people at the top of the organisation telling people who deliver health care that they should do something new.

A lot of those who represent the NHS of the past will argue that having a single organisation means that it is of course much easier to spread innovation. Having a single management hierarchy and culture means that all that needs to happen is that the people at the top get hold of the new ideas and tell the people at the bottom what to do. The reliance on authority and the management hierarchy is a major method of organisation for those that support the status quo and it will become one of the main debating issues in these posts about reform.

Some do believe that all you need to do is construct a powerful enough hierarchy, with clear enough communication, and change will inevitably happen all the way through the organisation.

The problem is that this doesn’t work. It can work if you are telling people not to do something. The simple message of “stop doing x” can just about get through a hierarchy and an organisation, but it doesn’t work if you are wanting people to do something different, new or difficult. And if you want people to innovate it is very difficult to shout at them down a management hierarchy to get them to do it.

In terms of innovation and improvement this is called the “push” method. You push it down into the organisation through leaflets, management directive tool kits – and nowadays web sites. Of course this has some impact. Those that are looking out for new things read the leaflets, get onto the web sites, and apply the tool kit. But what about those that are not looking for new things? Those who believe that the way they are doing things at the moment is OK. You can shout at them tell them to read the web site, but the push method doesn’t really influence them. Especially if they are working in organisations that find it difficult just to keep going every day – let alone to innovate.

Much of the work of improvement organisations in the NHS has been within the push method. The Modernisation Agency or the National Institute, work by getting together the very best new ways of doing things and broadcasting them. It gets some traction, but mainly the people who need to do this the most – the people, who are at the back of the distribution curve – just ignore it.

The next stage is to get the people at the top of the NHS to say loudly to “read this web site and do these things”. A few more do, but the push method doesn’t reach even a large minority.

Within public services we need to devise a pull mechanism which is different from individual patients reaching into their bank accounts and buying the newest thing. If that is the only method of pulling improvement into the NHS, then its basic principles are finished.

We therefore need something apart from the money from individual wallets to drag this innovation into the NHS. And that is why so many of us are talking about competition within the NHS. If organisations fail to innovate and others next to them do, then there need to be some plusses for the ones that do and some pain for the ones that don’t.

Given the correct incentive structure organisations will look to improve their services and will compete for patients. Within a reforming NHS patients don’t bring money from their own bank account. They bring money from the pool of finance raised by central taxation and organisations that compete for that patient choice.

Successful innovative organisations gain patients and gain resource. And they pull the possible innovations into their organisations. Unsuccessful ones lose resource because they are not pulling innovation into them.

Look at the productive ward – a great product of the National Institute. It’s a good idea. Every organisation should apply it to every ward. But some did and some didn’t. Then as the impact of the tariff on the economics of organisations runs through all organisations, the importance of improving nurse productivity becomes an issue for all organisations. The tariff, hospitals earning money and looking at their cost base, means that they become more and more interested in improving nurse productivity.

The productive ward is used by more and more hospitals.

Many of those that are against reform really don’t like markets and see that they have no place in health care. But it is these market reforms that have provided the incentives to organisations to drag improvement and innovation into the system.

Getting these incentives right ensures that innovation becomes universal in the NHS. All of this without individuals reaching into their bank accounts.

Having no incentives except shouting at people to be innovative ensures that innovation is kept in a small corner of the NHS.

Those in favour want to find the right incentives that will pull improvement into organisation by organisation and will punish those that do not do so have such incentives.

Those in favour of the status quo will imperil the NHS by not providing the incentives that will bring that innovation across the board.

The challenge to those who are wary of market based reforms in the NHS is to come up with levers of improvement that work as well.