Square pegs in round holes: why new structures never solve functional problems

ImageWhen you sit down for a meal, do you choose your food on the basis of the cutlery and crockery in front of you, or does your food determine your choice of utensils?

For most of us, it’s the latter; for soup we need a bowl and a spoon, a steak needs a plate and a sharp knife. What we do drives how we do it, form reflects function.

So why is it almost always the other way round in the NHS? Despite the fact that we all understand the theory, we continue to look at (and change) structures, with barely a thought given to the manner in which we would like the functions to evolve.

Thus, only recently, NHS England deputy medical director Mike Bewick apparently suggested that ‘GPs should form larger provider organisations’ in order to improve access, a structural solution to a functional problem if ever there was one. Nothing was reported on what the problems with access actually comprised, suffice it to say that larger practices were deemed to be the answer.

Now I don’t know about you, but it seems to me that if I want good service in my personal life, I tend to go to small providers (restaurant, butcher, vet) rather than the faceless bureaucracy I get when I deal with a mega-provider; the only advantage that they offer is lower pricing, usually at the expense of customer service.

But that specific example is missing the overarching point; to solve the GP access problem properly, we need to understand its underlying causes; the sticking plaster of any simple structural solution simply isn’t enough. If the issues are about inappropriate demands (A&E anyone?) then putting in more ‘supply’ will merely exacerbate the problem. If it is about inflexibility in skill mix adaptation, then larger practices would be a very expensive (and equally inflexible) way of solving the problem; and so on…

So why do we seem so ready to turn to structural solutions? Firstly, structures, whether physical buildings or organizational hierarchies, are easy to conceptualise, and we all prefer things to be simple rather than complicated, even if simplicity is reductive and ultimately unhelpful.

Secondly, simple interventions are usually easier to measure than complex ones, something that is particularly important to politicians, who want to be able to point at new edifices (preferably with walls, roofs and a plaque to unveil) and say ‘I did that.’

Thirdly, structural solutions calm the insecurities we all have when life changes (as long as I know where my desk is, my job must be safe) and so help us to cope with uncertainty, even if that protection is illusory.

However, apart from the fact that structural solutions are rarely more than symptom control (using a medical analogy), they also distract us from sorting out the underlying problems. If my non-steroidal medication keeps my repetitive strain injury quiet, then I don’t have to think about changing my working practice to make real changes to the way I work, thus keeping life simple, immediate, but ultimately still broken.

The only way to start solving the underlying problems of the NHS (and of most large macro-systems, for that matter), is to take a cool, dispassionate look at what we’d like the system to produce, and then work out what is required to meet that brief. Of course, much compromise and sleight of hand will still be required, as we can never really start from a blank sheet of paper once such a large system is running.

But at least we can sort out the real diagnosis and come up with a treatment plan, rather than botching yet another short term fix merely because there are twenty other similar problems sitting in the waiting room.

The best compromise may well be to carry out such ‘whole body diagnoses’ on small but complete ‘micro-systems’ (a single practice, a CCG, even a hospital Trust), rather than looking for root and branch reform of the whole creaking organization at once. As long as the analysis and the treatments in the small unit take into account its interfaces with the larger system, then one may have a way of carrying out an holistic, meaningful analysis of the functions of an entire entity, and beginning to introduce the changes needed to improve that functionality.

Not only would the scope and size of such an approach give it a better chance of being effective, it would also allow the inclusion of two other key factors vital to the success of any change management programme: ownership and ‘buy in’ from those involved, and the start of a cultural change ‘cascade’ whereby success amongst those who are in at the start of the process appeals to the later adoptors and tempts them into the programme.

So, CCG Chairs and practice managers, are you up for having your micro-system analysed and put onto a change management regime? It’d be enlightening, cost effective, and very productive.  It’s something that I would be really keen to explore; all we need now are the pump priming funds…

This article is based on a piece published in Pulse on 27 August 2013.