When conversation is better than commissioning

A hero of mine, Enrico Coiera, once wrote a paper entitled "When conversation is better than computation" you might expect that kind of title from a luddite, with anti technology principles, but at the time Enrico was a Vice President at Hewlett Packard in their special research division.

Enrico argued that despite all the computational power available there were times when developing a relationship and establishing communication was the right thing to do.  I would like to suggest that the same principle might apply to commissioning. We have services that could be improved by stepping back, starting again with a clean sheet of paper and buidling the perfect pathway. Although this risks the God Complex, it will be appropriate at times.

What would happen with conversation?

If there was an outcome which was less than expected it could be talked through and the incremental changes required could be put in place without the need to start again, spend hours redefining and re-procuring the system.

Cynic will argue that talking will just support the status quo, but they miss the point, the incremental change means that the status quo moves whether it wants to or not.

Perhaps the next time you have a letter from a hospital which asks you to look up blood results on the same hospital system the consultant could use, and furthermore to send it to the consultant, rather than moaning about being made to act like  a house officer (F1) you could always initiate a conversation- try it, you'll be surprised.

Losing the God complex

It's often said that doctors act like they're gods. They believe they are right, have the solution, can totally understand the problem. Ok this is a caricature but it has a basis in health systems. We often believe that there is a right answer, that we "know" the right thing to do in any situation. Our science of evidence based medicine simultaneously destroys and supports this view. It destroys the god complex by providing proof of the effectiveness of an intervention in any clearly defined, tightly controlled situation. However, armed with "the evidence" it delivers cast iron certainty that we are right, totally, infallibly correct.
The trouble is that health systems are not simple randomised double blind controlled trials. They are complex adaptive systems which do not respond in linear ways to defined, evidence based interventions. Complex systems require us to let go of the approach which says " I alone have the answer" and further more "this solution is the only one way to succeed".

Considering the NHS in it's current reformation it would appear that our solutions to the Nicholson challenge will emerge not from the top, not even the political direction of the Houses of Parliament, but instead from those near the front line who are able to experiment with the system, take chances on a trial and error basis, tinkering with the system to rapidly follow examples which provide good outcomes, rapidly abandoning features which produce lesser outcomes.

It won't be easy for us to shift from evidence based certainty to evidence based action not because it requires doctors and politicians to admit that they are not correct, but simply because it requires them to admit that they don't have the answer but are willing to learn.

Buy, Make or Partner?

One of the issues that seems to be hindering the NHS is the belief that the structures currently in place, both organisational and financial, are preventing the creation of a collaborative, patient centred system which offers the chance to deliver improved quality with improved productivity.
Granted we can argue that every organisation has a responsibility to achieve financial balance. However it is not the only requirement on NHS organisations. The real duty of every organisation is to deliver the best it can for it's customers, be they stakeholders, shareholders, paying clients or non fee paying service users.
The NHS has two blind spots, one is the payors, this Americanism translates to the commissioners, and the other is the service user, in our case the patients. Hospitals, practices, community trusts all forget that they have payors, commissioners who have an expectation of value and performance and instead focus on being the best organisation that they can. Although I don't believe we have a total blind spot for patients we often don't accord them the true status of customers, i.e having choice, power or purchase and a right to expect good service.

Is there a fix for this dichotomy, good organisation and good patient service?

The answer I believe is almost certainly, yes.

Commercial organisations can deliver financial success, efficiency and value. They also deliver customer focus and survive in harsh competitive environments. In that world view it seems obvious that competition is the answer to the NHS.

However if a commercial provider wanted to be the best it could, deliver most value it would also seek to expand it's market, it's influence. Examples such as Facebook, show a service provider who is now partnering with Spotify and other media providers to improve the range of services and value to it's users. Amazon achieved similar benefits when it bought out Audible to enable customers to choose printed, e-book and audio versions of it's products.

So it would seem that acquisition, alliance and collaboration is also the answer.

In the new NHS we now need an understanding of when to choose collaboration, competition or merger as the right blade on the NHS Swiss army knife.