Walking Backwards for Christmas

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

Glyn Griffiths is one of the noble band of WIHSC Associates on whom we rely for much of our work.  A pharmacist by training, and a highly experienced senior NHS executive by experience, Glyn takes a fresh look at the slow progress we have made in shifting care from hospital to community, and points out some home truths for the future.  By the way, if you find the title puzzling, you’ll have to read the blog…!

Walking Backwards for Christmas

I have recently been enjoying reading Anthony King and Ivor Crewe’s book “The Blunders of our Governments”. It is always perversely more entertaining somehow to read stories about how powerful people can get things badly wrong. It seems to make one feel a little more relaxed about the litany of screw-ups that decorate the career history of so many of us, and yet somehow many of us have survived to blunder another day.

The book covers a list of government initiatives over the decades which have patently and gloriously failed and it will not be hard for readers to recall many such initiatives. I will not steal the authors thunder by listing them all but it will not require a ‘spoiler alert’ to be aware that the Poll Tax, ID Cards and IT purchasing appear on the list.

Each blunder is analysed and I will leave individual readers to enjoy that analysis, and subsequent sections of the book describe some of the factors which fuelled, if not caused, the problem. It was here that I found myself recognising so many things I had come across in a lifetime in the NHS. Again I will not spoil a good read for you but I will take a look at one phenomenon which just spoke volumes to me – the section on ‘operational disconnect’.

So many of us believe that the right level to make a contribution, indeed the level to which we aspire, is variously described as developing strategy, crafting vision, or even shaping the debate. There are just so many phrases which allow us to feed our ego and believe that we are exerting the maximum influence on the future.

The chapter of this excellent book on operational disconnection immediately took my mind back to the days when commissioning first came onto the horizon in the NHS and our local commissioner took on that new role. At first it looked as if they were doing everything by the book. Time-outs abounded, senior figures cogitated and eventually their vision was made public. They would move as much healthcare as possible closer to the homes of the local population.

Indeed, to their credit, their work had gone further and they had developed both a strategy and a plan to deliver this lofty vision. The strategy was to strengthen primary and community care to cope with delivering the vision by moving money away from the secondary sector and reallocating it into primary and community care. The plan was to shift (let us say, to make the money sound vaguely real in today’s terms) £27m from secondary care over three years using the new ‘contracting’ process. Incidentally this sum was an entirely arbitrary figure arrived at because someone in a meeting said ‘it sounds about right’. How often, even today, has that phrase been heard in NHS meetings?

So what happened to the magnificent visionary plan? Well sadly I am ashamed to say that nothing changed at all, and I say that with a sense of shame because I was a part of the Trust’s contract team, who when it came to agreeing contracts created a picture of the devastating effects on secondary care waiting times and services that shifting money at that level would create. The poor souls who fronted up the commissioner team where at a complete loss and simply did not have the authority to agree what should be ‘reduced’ from the secondary care portfolio.

There was a gigantic operational disconnection at the level where change could really have happened. This example, whilst very old now, is not unique. King and Crewe cite a number of huge initiatives where policymakers are disconnected from delivery, and is peppered with quotes from civil servants like;

‘Ministers simply aren’t interested in operations.’

‘Always talk to the people who are going to have to implement a policy.’

So what could have saved us way back then? What did we not do? Luckily King and Crewe offer the answer in the form of a piece of military planning. It seems that military commanders when planning to move troops from point A to point Z routinely plan on the basis that they assume those troops have already arrived at point Z and consider what needs to have gone right – and what possibly might have gone wrong- in the course of the move from A to Z. In other words, they plan backwards from the desired end point. This really is not quite as bonkers as it initially sounds. For example, when the troops arrive at their destination will they be able to park their vehicles in a way that does not expose them to enemy aircraft? Who has the maps of the route and how can we get our hands on them? Who can tell us whether roads are passable in all weather conditions and who can tell us what the weather will be on the appropriate day?

Overlay on this the principle of Murphy’s Law: ‘If anything can go wrong, it will’; and you have on your hands a planning tool which can turn visions into realities.

Had we but imagined where we were going to deliver new community based services and who was going to use those services and crucially properly costed them then we may indeed have delivered more services closer to people’s homes. But we did nothing of the sort and so when contract negotiations took place all the secondary providers saw was a crude attempt to reduce their budgets.

Modern NHS planning is now based far more on good activity data and more transparent consequences but unless the journey as well as the destination is part of that planning then save your money and do not even buy a ticket for the trip!

Perhaps by now readers will have understood the rather strange title I chose for this offering. Choosing something so strange is based upon the editorial policy of the student newspaper I used to read back when dinosaurs roamed the earth and was an undergraduate. If the editor wanted to report on the elections for the Student Union Vice President in charge of Sandwiches then the article would be published under a headline like ‘Female Undergrad Molested by Hamster’. And yes we all read those articles and never found the hamster in question.

The title is that of a song written by Spike Milligan in 1956 and performed by the Goons. Yet another example of something that dates its author!

By Glyn Griffiths


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