The unseen costs of fads and fashions in healthcare policy and management

Healthcare policy and management is somewhat prone to fads and fashions in how ideas develop and are adopted. There also tends to be a cycle in some of them, for example, in a number of countries reforms decentralising control of the health system.

There are costs to not being part of the group who are adopting and using the current ideas. One may not be at the centre of the more interesting and exciting elements of organisational life and you may be excluded from conversations by jargon and more importantly, from funding opportunities.

Some fads and fashions prove to be both short lived and of limited positive impact but just because an idea has a high level of currency doesn’t mean it’s a bad one or that attention should always be directed elsewhere. However, too much focus on the idea of the moment can have some less desirable effects.

First, is that insufficient attention is given to less glamourous areas that may be as important and so opportunities are missed.  One example is the neglect of basic administrative systems. Failure demand – demand that arises from a failure to do the right thing first time leading to rework and further non-value adding transactions are built into many processes in both primary and secondary care. These problems are very clearly a major source of dissatisfaction to patients and staff and a huge source of waste. Many of the stories people relate about their encounters with the NHS, and other large systems, are about these problems. No one says my main complaint about the hospital is that its strategy isn’t very good, but they do complain about the organisation and administration. But fixing this is boring, difficult, requires continuous effort and in many cases people tend not to notice systems that work well, they are invisible until they don’t. Big shiny ideas are more attractive.

A second consequence is that we miss weak signals from issues that are emerging and may prove to be highly significant. That means that when they do become serious issues we are poorly prepared even though often we are not surprised. Examples of this include:

• The growing problem of access in areas such as dentistry, child and adolescent psychiatry
• The shortage of key staff groups and major discontent amongst clinicians
• The growth of health care acquired infections
• The opioid crisis in the USA and Canada
• The issue of delayed transfers of care in the UK

These share some common factors. Firstly, they tend to be the result of incremental change and so they creep up slowly sometimes over quite long periods. The tipping point might be a big event triggers the issue being notice, but these are almost impossible to predict. Secondly, they often lack a strong and simply unifying narrative, sometimes because the problems are complex and difficult to articulate in a compelling way. It might be that the advocates for the issue lack access to communication channels or, if they do, they are perceived as representing a special interest and therefore their arguments tend to be accorded less value or discounted. In some cases, these issues also recur in ways that suggest that the problem was never really solved. Child abuse and murder inquiries from Maria Colwell in 1974, through Vitoria Climbie 2003 and Baby P 2009, the succession of maternity inquiries leading to promises of ‘never again’ where ‘depressingly recurring’ would be more accurate.

Being ready with methods for thinking about these types of problems and having done some of the basic work to understand what is happening and the solutions that might be available would be advantageous. This requires some change in what we do and focus on. This might include:

• Looking at areas that are not receiving much policy or management attention and that have a significant influence on how the health and care system operates. Those where there seems to be little progress or small steps in the wrong direction often merit more attention.
• Listening to those that have less visibility and voice. Community services are a good example of this. Learning disabilities even more so. Because there is a tendency for some of these to be prone to catastrophising or hyperbole to get heard does not mean that there is not something in it. It turned out that there really was a major problem in general practice – just because ‘they would say that’ doesn’t mean that they are wrong.
• Tracking trends in other health systems can be helpful.
• Voices outside the system are also important in this approach to scanning widely but here it is harder to distinguish signal from noise, particularly since Covid where this ratio has shifted.

This needs to be combined with some flexibility and a willingness to believe that you might have missed something or be wrong.  This seems to be the most difficult thing of all.

Insight piece from Nigel Edwards, PPL Senior Advisor