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Achieving great service is straightforward if unconventional: give customers/patients/service users what they need. However, convention dictates that to adopt this approach will lead to expensive ‘gold-plating’ of services (quality service but at higher costs).
Instead leaders and organisations seek to follow convention and manage their activities by protecting budgets, imposing access restrictions via criteria or eligibility introducing service level agreements and focusing on efficiency through reducing transactional or unit costs.
Yet, the real paradox is that an explicit focus on managing activities paradoxically increases the very thing organisations seek to reduce – cost. Convention decrees that the answers to problems are already known and pre-prescribed solutions can be delivered through meticulous plans and reports. As a consequence these change approaches fail to deliver in practice.
Take conventional healthcare commissioning in the NHS – a person as a health and/or social care need; their need is assesses and then sooner or (most often) later a service is first commissioned then provided by different professionals. Service level agreement met, project milestone ‘green-lighted’ and ticked.
What happens is because services are not designed around the need(s) of the person/patient/service user, they represent to the service in the vain hope that their need(s) maybe better met. Professionally, the response to this problem is to repeat the process of assess, commission and provide. The outcome experience of the person/patient/service user is that they continue to represent and costs rise. Why does this happen? It is because the mind-set is misguided.
Conventional business change needs to change
Conventional change or improvement relies on a wrong-headed ‘back-to-front’ perspective. What is meant by this phrase is a rear-guard focus on removing cost by reducing activity and expecting patients to change their behaviour. It results in an obsession with activity volumes and ‘bottom-line’ costs. The one problem with this approach is that it doesn’t work. Back-to-front thinking always leads to distortion of organisational performance and higher costs.
The mechanics of conventional change follow a typical path. Invalidated hunches, opinions and/or data consisting of worthless aggregated activity, arbitrary benchmarking and/or cost volumes are used to identify problems.
Understanding the patient or service user (as opposed to non-user public) perspective in this process is rarely, if ever sought. Agreeing appropriate governance arrangements typically loom large at this point and take-up not inconsiderable internal discussion, effort and time.
Much time is consumed completing a litany of project management induced paper-chasing reports such as project initiation documents or PIDs. Once signed-off this document helps formulate a project plan which is established to solve the preconceived problem. A business case is then written which outlines time, costs and predetermined outcomes.
These outcomes are then ‘monitored’ through office-based completion of reporting documents such as highlight reports full with activity and cost volumes with ‘traffic light’ systems – green for good, amber for somewhere in between and red for bad. None of this involves spending time in the work and empirically understanding ‘why’ things are the way they are.
Improvement activity is often relegated to time-limited projects and people who sit outside of the actually work. Disproportionate time and effort is then spent on conducting public consultations (‘the blind leading the blind’) which replace the opportunity to generate empirical knowledge of what is actually happening and causing problems at the sharp-end, in the work.
Performance metrics derived at the business case stage tend only to measure activity on whether a project is completed ‘on time’ and ‘to cost’. Little regard is made of how much operational improvement is achieved in resolving the real problem(s).
‘Off-the-shelf’, standardised solutions are mandated that usually involve automation or greater use of technology (sometimes referred to as ‘channel shift’ or ‘digital-by-default’); sharing or outsourcing services; restructuring to establish new ‘target operating models’; rationing buildings and service provision; charging and trading services and/or reducing staff numbers. Here abstract cost-benefit equations are the order of the day.
Unless consultants are engaged, ‘delivery’, ‘execution’ or ‘implementation’ is then solely contracted out to frontline staff who are left to try and make the problem fit the predetermined standardised solution(s). Benefits realisation plans are written remotely and focus on the completion of activity tasks not performance improvement.
Consequently, ‘change’ seeks to solve symptoms not address root-causes. The predictable result of this way of approaching improvement are failing projects, higher costs and poorer service as experienced by patients.
Tomorrow I will outline the more intelligent way to conceive of how to change for better and undertake meaningful performance improvement.
The Perceived Problems
Healthcare providers and commissioners face multiple challenges. They increasingly recognise that the NHS must change the way it operates to effectively meet future challenges. Commonly held opinions dominate discussion – from a belief in rising demand for healthcare services, costs associated with technological and treatment advances, increasing public expectations and a funding gap of £30 billion.
Conventional Approach to Change
Conventional approaches adopt an internal activity and cost-reduction focus. They typically involve workshops to agree service models and action plans. These tend to be accompanied by artificial modelling of service capacity and staff resourcing which arrive at ‘optimum levels’ of activity ‘contacts’ that are then tested in workshop environments. Following this type of analysis, work is undertaken to standardise service processes so as to reduce variation and waste.
Inherent within this approach is a belief that there is a capacity problem; solutions can be found via workshops and abstract planning models that determine staff resourcing. Workforce planning often ensues to try and address the perceived problem of the ‘plateaued worker’. The logic equates to stable staffing levels and standardised processes which will lead to activity and cost reduction gains. Standardising processes typically take place in workshop environments, far are removed from where the real work occurs.
Yet, in service organisations, seeking to standardise processes often creates problems. In healthcare there is high variability of patient demand; standardising processes will only cause service performance to fall (as the standard offering fails to meet the natural variation in needs) and costs increase (as the service provider’s standard work leads to more activity creating additional process waste and rework).
Adopting a Different Tact for Better Results
To address these challenges I have pioneered a new and refreshing approach to healthcare analysis – the Consumption Demand Method™. The starting point for improved services at less cost rests on more intelligent use of data to inform future performance improvement through intelligent system and service redesign. This alternative approach to realising better healthcare services and less cost begins with looking at healthcare data differently, not from an activity but patient-centred perspective.
Unlike existing practice, this work establishes time-series data to understand the true nature of person-demand for acute services in order to better understand the root-cause(s) of service challenges facing healthcare commissioners and providers alike. From understanding patient demands it is possible to develop knowledge as to ‘who, where and why’ these demands exist in the first place and how best to meet them in order to provide more effective, person-centred services at less expense.
The Method is directly influencing commissioners and providers, helping to challenge conventional thinking about healthcare demand. A recent study of secondary healthcare demand reveals counter-intuitive truths about the true nature of service demand. Unlike activity-levels, patient-centred demand in secondary care is not rising, but entirely stable and predictable. This is bad but good news.
Rather the root-cause for increases in activity (and associated costs) lay in the inability to successfully design service responses based on genuine understanding of patient needs. This inability drives ‘amplification of demand’ from relatively small numbers of patients – the ‘vital few’.
I have utilised the Method to establish a series of ‘demand-led’ improvement projects. These include work in the following areas:
- Primary care transformation
- Delayed transfers of care (DTOC)
- Accident and emergency
- Referral time to treatment (RTT)
- Integrated diabetes service
- Sustained high-cost users
- Long-term conditions
- Out-of-hours provision
- NHS 111
Moreover, the Method has also been successfully used to perform wide-ranging reviews of medical specialities and existing improvement schemes. One such review of a two-year QIPP scheme in paediatric urgent care, which cost seven figures to resource, found that the local healthcare economy would have saved more money by not doing anything! The work analysed demand for services against stated project aims, proposed changes in both design and process and realised operational savings.
The approach and work also acts as a catalyst in providing knowledge and skills transfer to senior clinicians, commissioners and specialists in the analysis of consumption data and redesign of service models and care systems against patient-level demand as opposed to arbitrary and abstract activity indicators.
In fact, the Method effectively identifies ‘business gaps’, encourages thinking about the real problems, asks intelligent questions and provides the means to sustainably improve performance. It deliberately keeps abstract programme and project management, risk assessments and associated document reporting to a minimum as they impede real change.
More intelligent use of data in this way can better inform future commissioning and operational improvement through system and service redesign. After all the NHS has exhausted all other misguided approaches – standardising; over-medicalising; functionalising and commercialising operations. We need to humanise healthcare and focus as much on care needs as medical treatments.
For more information see Front-to-Back Thinking – humanising healthcare – Dibley Consulting or contact me at email@example.com