See you and raise you

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Polling day is next week. In a world of perpetual campaigning, it’s helpful to finally get a result – before the cycle starts all over again. If you think we’ve got it bad, try living in the States. Candidates are announcing now and it’s not even 2016 yet.

The NHS always features highly in electioneering. Remember Jennifer’s ear? In this campaign the parties are vying to fill the supposed £8b black hole. It’s like watching a poker game: I’ll see you and raise you. All this brings to mind the reference to the NHS by Nigel Lawson when he was Chancellor of the Exchequer: The closest thing the English have to a religion, with those who practice it regarding themselves as a priesthood.

I raise this as background to the second of six blogs exploring major issues facing NHS boards, in this case operational effectiveness. This is one of the key areas that Monitor highlights when it sends its improvement notices to Foundation Trusts. The focus here is on how well the Board and its members know their business. Boards have been challenged over the years to operate at a strategic level – The Intelligent Board stated a decade ago: A good rule of thumb is that boards should aim to spend around 60% of their time on strategic matters.

Among other things, it was this focus on strategic issues that caused the Board of Mid Staffs to take their eye off the operational ball. As Robert Francis observed: A theme of the evidence about the Board has been reliance on the distinction between strategic and operational issues and a disclaimer of responsibility for the latter. The distinction does not justify directors not interesting themselves in operational matters when it is known that governance systems are either not in place or are untested.

In this rush to strategy, Boards have sacrificed their operational focus. The distinction between the two is a big grey area in any case. Consider the operational issues that bite Boards in the tail, and then become strategic – A&E access and delayed discharge stand out. So Boards need to give more consideration to operational issues. Harvard professor Michael Porter gives us a clear view of this: Operational effectiveness means performing similar activities better than rivals perform them.

Applying this to the NHS, there are a few things that Boards can consider. First is the information at hand for decision making. The NHS is awash with data, but this is not effectively turned into information, much less intelligence, knowledge or insight. Board reports can contain performance papers that are 40+ pages long, dense with tables, but light on interpretation. In 12 years as a non-exec, I was continually prompted to ask, “Please explain what this tells us”. When I see such dense reports, the observation of the French mathematician and scientist Blaise Pascal comes to mind: I have made this letter longer than usual because I lack the time to make it short. So spend the time to turn the data into information.

Second is standardisation. If McDonald’s can flip its burgers the same way across the world, why can’t the NHS standardise some of its core processes? Take drug trolleys. The hospitals I visited with my impact group as part of the Academy’s Frontline nurse leadership programme showed the variation across wards in how drug trolleys are provided. As a core part of the production process, this is ripe for standardisation. Other areas include prescribing, prostheses, procurement, etc. Boards can responsibly challenge ‘the way we do things around here’.

Finally, there is variation. In facilitating a Board effectiveness workshop, we discussed the fine of £4m that was going to be levied because the trust was going to breech its agreed C. diff target. Board discussion was on how to get back on target, not about ‘joining the dots’ across key performance areas to see what real improvement could take place and how services could be redesigned. When we agreed what % of patients with C. diff would die, I observed that the Board has agreed a target to harm patients. This led to some interesting discussion. The challenge for Boards is not to do current things better, but to do things differently, utilising technology and resources at their disposal – as Michael Porter says, to perform similar activities better than rivals.

Rather than focusing too much on strategy, Boards would do well to know their business – get the right information for decision making, improve standardisation and reduce variation. Maybe in this way we’d be able to end the poker game and stop raising the amount of money the NHS needs to get by.

One thought on “See you and raise you

  1. The most important thing is to have Board level good leaders. This applies for both Non-Exec and Execs. Sadly NHS appoints many Board level leaders without any training in leadership. This is the fundamental problem with our NHS.

    The Chairman and Non-executive Directors fundamental aim is to challenge their Executive Directors and they must challenge them constructively, positively and look at evidence to support quality, safety, governance, staff and patient engagement. Most NEDs do not know how to do it and not properly trained to do it.

    NEDs main role is to protect patients and staff. Happy staff – happy patients NHS must train all NEDs to look at organisational governance and to challenge the executive directors.