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Transforming for value


22 April 2016

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The visionary Sir Muir Gray explains the crux of effective transformation: relationships, a focus on morale rather than money, and an unnerving focus on the population that commissioners serve

The visionary Sir Muir Gray explains the crux of effective transformation: relationships, a focus on morale rather than money, and an unnerving focus on the population that commissioners serve

As the sustainability and transformation plans (STPs) rose to the top of clinical commissioning groups’ (CCGs) to-do lists across the country, we spoke to Sir Muir Gray, to talk about the plans, establishing better relationships, and the right way to go about transformation.
For the STPs to work it is vital that everyone involved can put aside their past disagreements and act for the good of the population, he says, to ask ‘what is this system of care for? What are we trying to achieve?’ rather than drowning in insignificant detail, he states. We should focus on knowledge and morale rather than money, he advocates. The Commissioning Review meets the man behind the vision.

So what do you think about the idea of tackling long-standing tricky issues, such as two poorly-staffed A&Es near each other, through the STPs?
Well, it is the only way. Bureaucracies are very important, but not for tackling tricky problems. Tricky is a good word. These are non-linear problems, which bureaucracies cannot tackle – no matter how much you inspect them or regulate them, or try and guide them.
So what you need to do is to get everybody working together, and the model, of course, is the ant colony. The ants all work for the good of the colony. The solider ants do not try and outwit the worker ants, or make money from the worker ants. And the queen ant does not tell them what to do. She lays eggs. It is not a bureaucracy; she has got her job and she gets on and does it. So the STPs are the process [of reducing bureaucracy]. Remember, Eisenhower [34th US president] said: plans are useless, planning is essential.

It is interesting you mentioned relationships as Jim Mackey, chief executive of NHS Improvement, was speaking at a recent King’s Fund event. He was talking about the kind of things that he has seen locally, for example people deciding on the leadership for the STPs without the main provider being in the room.
Well, it is not the way the ants do it. I bought the number one book on ants years ago, £177, and there is a chapter on altruism; the ants are altruistic. People have to think of the good of the population they are serving over their own good.

How can integration be done if there are poor relationships?
Impossible.

So if I was in a CCG and had a long-lasting negative relationship with the local authority, what do you think needs to happen to get the relationship back in a constructive place?
It is a therapeutic problem. It usually needs some outsider or a consultant to come in; we should have more therapy. People have to recognise that it is feelings and emotions as well as budgets that are important. People need to speak with respect to one another.

You recently spoke about the link between the military and the NHS. How do you think that military systems can be applied to healthcare?
I have not been in the military but l have read a lot about it, and what the military is good at doing is setting a strategic objective, asking what are we trying to achieve and then letting people get on with it.
Right now we are clear about what we are trying to achieve, but instead of getting into the detail, for example, “do you need four band 7 nurses and two band 8 physiotherapists?” and trying to standardise the delivery, that is left to the local commanders in the military.
Also, I’ve learnt the importance of morale. Brigadier Slim, who is one of the most highly respected Second World War generals, said: “It is all very well having a good strategy, but we depend upon the resilience of the frontline fighting man.”

Do you think that NHS England and other central bodies have not fully recognised that? And whether central command needs to do more about the morale; that it needs to come from a central place rather than local bodies?
Yes. But it is difficult to do; it is difficult to do from the centre.
I think the first step is to talk about it, but all we see is articles about money. It is the other ‘M’ word [morale] that I believe we need to be thinking about. And it is just emerging now as an issue, and in my view, it is much deeper than the junior doctors’ strike and, in some way, the pay issue confuses it. Is the pay the real issue or is it a symbolic issue? It is probably a bit of both. Because quite often strikes are due to some other tension that is there and people will focus on the money.

So what do you think are the most prominent issues for CCGs, and how can they overcome them?
I think in a way now we are seeing an existential challenge for the CCGs, and my own concern about them has always been the arbitrary nature of their boundary; that many of them do not relate to boundaries, natural boundaries, or the way that patients flow.
The last thing we deserve is a reorganisation [of the NHS]. I have been through 22. So the key issue is, I think, as you were describing earlier: can they forget about past insults and enmities? Put a map up on the wall and be accountable for the population they serve; not to NHS England, that is necessary, but obey the idea of the population accountability as a key theme.

How do you think the CCGs can make space for that when they are drowning in STP plans and are so busy?
Well, you have to prioritise. And the key thing we [Right Care] wanted the CCGs to do was to identify the needs of their own population and allocate resources as well as they could.
My own view is they get too involved in detail. For example, one CCG wanted to cut the hearing aid service. Well, that is just a tiny thing. They should really not be getting so engaged in the detail and looking more at the population and the allocation of resources.

I heard that you were looking for CCGs to try the STAR tool, what is that?
It stands for: socio technical allocation of resources. You take a problem or a population, like people with eating disorders, and then you write down everything you could do, from prevention through to terminal care. And then, with the relevant patients in the room, the STAR tool allows you to estimate the benefit you get from these different parts of the pathway. And it combines the research, and uses simple diagrams, so in the room you can see that is where we are spending the money and that is the benefit we are getting.
But, as I say, it brings together all the spending – from prevention through to long-term care – and starts to shift resources from one budget to another.

What are the best ways to get value in the NHS?
The first thing is to see that, for the next 30 years, value is the most important concept. And there are three types of value: allocative value, how we share and spread the resources round; technical value, how we use resources for the whole population, not just the patients; and then personalised value.

What are the main challenges for CCGs when tackling variation?
If you look at the allocation of resources, there is about a two-fold variation in the allocation of resources for musculoskeletal or mental health, and about a 1.8-fold variation in many other resource allocations, for example, respiratory.
So I think the first thing the CCG should do is not just dive too deeply to one thing but look at how they are spending the resource across the piece, and compare themselves with the nine most similar CCGs. It is time for reflection.


Are commissioners supported enough to tackle variation?
No. We have appointed people called delivery partners, and this is new language, new concepts. And my own view is that it is not support that people need, it is training.

How can we improve shared learning in order to tackle variation?
By creating records, and managing that knowledge. My own view is that everyone paid more than £60,000 should submit a case report once a year on something they have done, either individually or in a team.
But we write down nothing. We will write down stacks of stuff in the NHS. Let’s take a problem like skin disease, costing £2 billion a year. If you tried to find out what people had done in the NHS to get more value from that £2 billion, it is impossible.
Big companies are very good at managing the knowledge produced by their own experience, so I think we need a casebook and that is what NHS Right Care is doing in partnership with the BMJ [British Medical Journal]. We are thinking of ways in which we can get people to record their processes.

Do you think data is key to great value and less variation?
Yes. Well, knowledge, not just data, it is knowledge. And the president of Toyota said, “Toyota is a knowledge company”. Well, so is the NHS. I know we have got buildings, and MRIs and drugs, but it is knowledge.
And there are three types of knowledge: knowledge from research – we call it evidence, knowledge from experience, and knowledge from data that we call information or statistics. So we [the NHS] are a knowledge-based company and we are not making good enough use of the knowledge that we have got.

And how do you think we need to make better use of knowledge?
Well, the approach I advocated was that every organisation needs to have someone at the board that is the chief knowledge officer, like the chief finance officer. And they can, all the time, be questioning, “I wonder what knowledge there is about this problem, and how are we collecting our knowledge, and are the people getting the right knowledge that they need for the job?”
So, an obsession with knowledge as opposed to an obsession with money.

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