Hamish Dibley

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‘Front-to-back’ thinking: the antidote to activity obsession disorder in the NHS

Activity obsession disorder: a curable condition

Activity obsession disorder: a curable condition

In healthcare we obsess with the wrong perspective – I call it ‘back-to-front’ thinking and it drives all NHS healthcare activity. It begins with asking the wrong questions of data, fixating on activity levels and volumes. The logic is as simple as it is unthinking: every annual budget cycle; we try to reduce costs by reducing XX% activity. The one problem with this approach – it never works. Costs spiral ever upwards whilst service outcomes either flat-line or reduce.

In NHS language this results paradoxically in an “over-performance” problem (which sounds positive but is in fact bad) – doing more activity than was stipulated in the contract plan. Consequentially, this leads to a counter-productive reliance on confrontational contracting as the primary commissioning lever. ‘Quality guru’ Brian Joiner refers to this type of behaviour as distorting the figures and the system. Everybody loses. We can’t afford to continue working in this manner.

In fact, it doesn’t have to be this way. There is an approach that is as different as it is revolutionary and has the potential transform healthcare. It can provide commissioners and providers with the wherewithal to achieve meaningful and sustainable change. The better alternative – what I call ‘front-to-back’ thinking is to start with looking differently at the data (as well as using innovative methods to generate new patient-centred data).

‘Front-to-back’ involves studying the nature demand for healthcare services not from the perspective of arbitrary activity numbers but real patients over time-series data. What this typically reveals is that the problem acute trusts think they have – one of rising demand is not actually true. The real problem is what I call ‘boomerang’ demand: comparatively small numbers of patients consuming disproportionate amounts of activity and resource as a consequence of services that are not designed for them.

Asking ‘front-to-back’ questions allows you to study the nature of activity that takes place on patients – how much is good versus wasted work; how much can be redesigned to work differently; how much activity actually should take place at different times, in different ways or not at all! Utilising this approach and its way of thinking then allows healthcare providers and commissioners the knowledge to undertake ‘intelligent system and service redesign’ around cohorts of patients not abstract service pathways.

The holy-grail of better services at less cost is achievable in health but it requires a different way of thinking and then acting based on what empirical data, not opinion, tells us. We can do much better than have to continuously rely on and fail with activity management approaches. Activity obsession disorder is a serious but curable management condition.