Easier, Better, Faster, Cheaper
Blog 5 in the Quality Matters: From Insight to Impact series
Quality Improvement (QI) is critical to delivering on the NHS Plan. This series of articles from Associate Directors, Ian and Laura, provides a personal and practical insight into how QI is needed more than ever.
Veran Patel, Director, Health & Social Care
I started in the NHS as a Transformation Programme Manager. I was full of enthusiasm and confidence. Coming from a Big Four Accountancy firm my opinion of myself was, embarrassingly, pretty high! Now I look back I realise how much there was to learn…
I was aligned to one of the three groups in the trust with its own transformation programme. The aim was simple enough: improve the quality of services and reduce the costs. Not unlike many transformation efforts throughout the NHS, then and now. I slotted into the cadence that was already established. Every week I’d attend two transformation meetings, back-to-back.
The first was named ‘Quality Improvement’. Various team representatives would attend and pitch their cases for why they needed more money and how they would spend it, normally on more staff, with rather grandiose promises of quality improvement.
“OK” I thought. “Improving quality in the NHS means more money and more staff”.
The second was the “Cost Improvement” meeting. Similar format as before, teams from the group would attend and outline their ideas for saving money. “Reducing the quality of the paper we use”, “Only printing when absolutely necessary”, “Challenging finance on some of the central costs allocated to the service”.
“OK” I thought. “Improving our cost position means cutting our cloth and getting our cost allocations in order”.
“Hazar!!! I am an accountant!” I thought. “With all my accountancy training how could I not succeed? We just needed to go through the budgets, apply a bit of innovation and ta-da! Challenge met”. That was the methodology I had been taught as part of my accountancy training. What could be so difficult?
Eagerly – I obtained the service budgets.
“Oh no”
It did not take an accountant to work out that no amount of tinkering with budgets was going to release the kind of money that was expected. By far the biggest cost was staff. And if we were going to save the money, we’d need to spend less on staff. But how?! Waiting lists weren’t good, staff were already burnt out and disgruntled. Taking more staff out seemed unfathomable!
I’d like to tell you that this transformation story ended well, that we unlocked the secret and achieved our goal. But I’m afraid we didn’t. We continued to tinker, randomly cut budgets, controlled vacancies, and failed. The quality got worse, the cost went up.
Roll forward a couple of years and I attended a training course, in Lean. Ideas and concepts were thrown around that made me think about transformation. Particularly, our approach to the double aim of Quality and Cost Improvement and how we needed to align these two imperatives, not treat them as mutually exclusive targets. The simple phrase was: EASIER, BETTER, FASTER, CHEAPER. This is actually referring to the order we should approach a transformation. The theory suggests that we should begin any transformation by making the work EASIER to do for staff. With a lightened burden, staff would be free to see how to make it better and flow faster, and the whole thing would ultimately become cheaper. Whereas, traditionally in the NHS we focus on Cheaper (arguably first) and then Better if we can manage that. I am not a clinician so didn’t have the benefit of relating these ideas to clinical practice. But, somewhat surprisingly, I was able to relate to the accountancy world I had come from…
As an accountant I was called a ‘fee – earner’. My job was to do work that clients were willing to pay for and generate income. In my world, that consisted of producing corporate tax returns. The fee earners were treated like royalty. Even though everyone had individual, high quality and functioning laptops, the centralised IT support was second to none. The on-site facilities guy consistently monitored the printer so it ‘always worked’ and our client files were sat next to us in the office. We had the best coffee machine that money could buy, onsite and for gratis. We all had twice yearly appraisals that supported us in our training and development needs, which were then well satisfied, offsite in a 5-star hotel.
At the time, I thought all this investment was all rolled up into the glitz and glamour of working for a Big 4 accountancy firm – we were so good we deserved it. But now I see this business model through a different lens – it was all about making the work EASY. The entire operation was designed to maximise the amount of fee earning work a person could do. No one had to wrestle with the printer to make it work, or spend 20 mins waiting for their shared laptop to start working, or head to Costa to get a decent cup of coffee, or go to 10 internal meetings a week (internal meetings happened once in a blue moon, if that). It all just worked.
So how EASY is the work of clinicians in the NHS? If you ask this question, I have no doubt they will say ‘not very’. We expect our clinicians to go above and beyond for the vocational job that they signed up for. Perhaps sound process, reliable IT, on-hand support staff and yes, good coffee, that serve the needs of the ‘fee earning’ staff are seen as nice perks only afforded to the private sector. But to see these as ‘perks’ is to completely misunderstand their intention. It’s about allowing staff to do as much of the ‘fee earning’ work as possible, so that staffing costs are kept as low as possible.
So back to the transformation conundrum – how do we draw together the cost and quality imperative in the NHS? We start by understanding what our clinicians are doing. Not to ‘check up’ on them, but to understand how easy or hard it is for them to do their work. Our experience of the NHS suggests that’s somewhere between 15-20% of a clinician’s time is spent with patients. The rest of the time is taken up by wrestling with systems and processes that make life difficult. A focus on reducing that burden by only a modest amount could perhaps see us near double time spent with patients to 30-40%, effectively doubling the productivity of our workforce. Not only that, with twice the productivity we can afford the time to: get the quality right; improve safety; faster flow patients through our systems; and inevitably, save money.
Easier, Better, Faster, Cheaper – in that order!
Laura Woodward and Ian Railton are Quality Improvement (QI) experts and are Associate Directors at TIAA. This series of fortnightly blogs are their insights into a long career and successful track record of working with healthcare organisation to improve productivity and better outcomes for patients.
Click below to catch up on the other blogs in the series –
Quality Matters: From Insight to Impact; Before solving a problem, you must first understand it
Quality Matters: From Insight to Impact 7 Traits of an Improver
Quality Matters: From Insight to Impact – Control Versus Autonomy – Seeking the Balance