This was an interesting headline to see on the front page of a newspaper yesterday!
The Top Man of the NHS is openly challenging the current Centralisation-is-The-Only-Way-Forward Mantra; and for good reason.
Mass centralisation is poor system design – very poor.
Q: So what is driving the centralisation agenda?
A: Money.
Or to be more precise – rather simplistic thinking about money.
The misguided money logic goes like this:
1. Resources (such as highly trained doctors, nurses and AHPs) cost a lot of money to provide.
[Yes].
2. So we want all these resources to be fully-utilised to get value-for-money.
[No, not all – just the most expensive].
3. So we will gather all the most expensive resources into one place to get the Economy-of-Scale.
[No, not all the most expensive – just the most specialised]
4. And we will suck /push all the work through these super-hubs to keep our expensive specialist resources busy all the time.
[No, what about the growing population of older folks who just need a bit of expert healthcare support, quickly, and close to home?]
This flawed logic confuses two complementary ways to achieve higher system productivity/economy/value-for-money without sacrificing safety:
Economies of Scale (EoS) and Economies of Flow (EoF).
Of the two the EoF is the more important because by using EoF principles we can increase productivity in huge leaps at almost no cost; and without causing harm and disappointment. EoS are always destructive.
“But that is impossible. You are talking rubbish … because if it were possible we would be doing it!“
It is not impossible and we are doing it … but not at scale and pace in healthcare … and the reason for that is we are not trained in Economy-of-Flow methods.
And those who are trained and who have have experienced the effects of EoF would not do it any other way.
Example:
In a recent EoF exercise an ISP (Improvement Science Practitioner) helped a surgical team to increase their operating theatre productivity by 30% overnight at no cost. The productivity improvement was measured and sustained for most of the last year. [it did dip a bit when the waiting list evaporated because of the higher throughput, and again after some meddlesome middle management madness was triggered by end-of-financial-year target chasing]. The team achieved the improvement using Economy of Flow principles and by re-designing some historical scheduling policies. The new policies were less antagonistic. They were designed to line the ducks up and as a result the flow improved.
So the specific issue of Super Hospitals vs Small Hospitals is actually an Economy of Flow design challenge.
But there is another critical factor to take into account.
Specialisation.
Medicine has become super-specialised for a simple reason: it is believed that to get ‘good enough’ at something you have to have a lot of practice. And to get the practice you have to have high volumes of the same stuff – so you need to specialise and then to sort undifferentiated work into separate ‘speciologist’ streams or sequence the work through separate speciologist stages.
Generalists are relegated to second-class-citizen status; mere tripe-skimmers and sign-posters.
Specialisation is certainly one way to get ‘good enough’ at doing something … but it is not the only way.
Another way to learn the key-essentials from someone who already knows (and can teach) and then to continuously improve using feedback on what works and what does not – feedback from everywhere.
This second approach is actually a much more effective and efficient way to develop expertise – but we have not been taught this way. We have only learned the scrape-the-burned-toast-by-suck-and-see method.
We need to experience another way.
We need to experience rapid acquisition of expertise!
And being able to gain expertise quickly means that we can become expert generalists.
There is good evidence that the broader our skill-set the more resilient we are to change, and the more innovative we are when faced with novel challenges.
In the Navy of the 1800’s sailors were “Jacks of All Trades and Master of One” because if only one person knew how to navigate and they got shot or died of scurvy the whole ship was doomed. Survival required resilience and that meant multi-skilled teams who were good enough at everything to keep the ship afloat – literally.
Specialisation has another big drawback – it is very expensive and on many dimensions. Not just Finance.
Example:
Suppose we have six-step process and we have specialised to the point where an individual can only do one step to the required level of performance (safety/flow/quality/productivity). The minimum number of people we need is six and the process only flows when we have all six people. Our minimum costs are high and they do not scale with flow.
If any one of the six are not there then the whole process stops. There is no flow. So queues build up and smooth flow is sacrificed.
Out system behaves in an unstable and chaotic feast-or-famine manner and rapidly shifting priorities create what is technically called ‘thrashing’.
And the special-six do not like the constant battering.
And the special-six have the power to individually hold the whole system to ransom – they do not even need to agree.
And then we aggravate the problem by paying them the high salary that it is independent of how much they collectively achieve.
We now have the perfect recipe for a bigger problem! A bunch of grumpy, highly-paid specialists who blame each other for the chaos and who incessantly clamour for ‘more resources’ at every step.
This is not financially viable and so creates the drive for economy-of-scale thinking in which to get us ‘flow resilience’ we need more than one specialist at each of the six steps so that if one is on holiday or off sick then the process can still flow. Let us call these tribes of ‘speciologists’ there own names and budgets, and now we need to put all these departments somewhere – so we will need a big hospital to fit them in – along with the queues of waiting work that they need.
Now we make an even bigger design blunder. We assume the ‘efficiency’ of our system is the same as the average utilisation of all the departments – so we trim budgets until everyone’s utilisation is high; and we suck any-old work in to ensure there is always something to do to keep everyone busy.
And in so doing we sacrifice all our Economy of Flow opportunities and we then scratch our heads and wonder why our total costs and queues are escalating, safety and quality are falling, the chaos continues, and our tribes of highly-paid specialists are as grumpy as ever they were! It must be an impossible-to-solve problem!
Now contrast that with having a pool of generalists – all of whom are multi-skilled and can do any of the six steps to the required level of expertise. A pool of generalists is a much more resilient-flow design.
And the key phrase here is ‘to the required level of expertise‘.
That is how to achieve Economy-of-Flow on a small scale without compromising either safety or quality.
Yes, there is still a need for a super-level of expertise to tackle the small number of complex problems – but that expertise is better delivered as a collective-expertise to an individual problem-focused process. That is a completely different design.
Designing and delivering a system that that can achieve the synergy of the pool-of-generalists and team-of-specialists model requires addressing a key error of omission first: we are not trained how to do this.
We are not trained in Complex-Adaptive-System Improvement-by-Design.
So that is where we must start.