April 26, 2018 Nick Downham

The NHS is fixated on trying to do the wrong thing ‘righter’

Nick Downham – Oct 2018

© Cressbrook Ltd 2018 – All Rights Reserved

You may have caught the film War Machine  on Netflix, staring Brad Pitt as an embattled general trying to make sense of the US war in Afghanistan. Based on a true story, he plays General Stanley McCrystal, who has been sent in to command the war effort in Afghanistan after it has got bogged down (the US military intervention in Afghanistan is the longest ‘war’ the US has ever fought).

Despite the title of the movie, it is no gung ho war movie. It is a tale of hubris and celebrity generals. Most importantly for those working to improve health and social care services, it provides a superb example of a very common trap organisations fall into when making improvements. I see this day in, day out as I travel the country helping healthcare organisations of all sizes:

The very beginning sees Brad Pitt’s general march into view and into his new office. Marching with his team in tow, chest out, arms swinging, full of purpose, gravitas and confidence. He has been taught and has decades of experience of the way the US military fights wars. It is just the previous US general has not been doing it right.

Fast forward to the end of the film, and Brad Pitt’s General has come undone. He has not succeeded and he has found his methods (the methods of the military) ineffectual for the type of war being fought in Afghanistan. So his replacement has been sent. This time played by Russell Crowe, the new general arrives as the HQ and marches in. Chest out, arms swinging, full of purpose and confidence. He is going to use his decades of experience in how the US military fights wars to sort things out. It is just the previous US general has not been doing it right.

The new general’s plan, like Brad’s general’s plan, revolves around doing the wrong thing ‘righter’ ** . I am just going to try harder and do it better. Do broadly the same thing (they are all trained in the same way and in the same place). He is just going to do it ‘righter’.

What if the very premise behind the thing he is doing is wrong?

Switching settings to the NHS, I see this all the time. We seek to make things better, rather than do better things*. In response to much of the capacity crisis we have in the NHS hospital system, we have things like discharge teams, front door response teams, discharge lounges, heavy management focus and assessment units. All of these interventions are around making the best of the current situation, expediting, creating more capacity and greater gatekeeping. New managers replace old. The thinking does not change. Wrong thing ‘righter’. There is comparatively little focus on challenging ourselves whether we are doing the right thing in the first place.

For example we focus on getting frail people out of hospital or stopping their admission at the front door, rather than focusing on delaying the onset of frailty in the first place. Or we ‘tell’ nurses to be compassionate, rather than explore the reasons behind how the system makes it impossible for them to be so.

The solutions that we tend to come up with try to make the current more efficient, without questioning the work in the first place. This is because we tend to be bound by what we know and recognise. We are often trained in the same way and have the same experiences, just like the generals coming out of West Point. Sometimes the system needs to change, rather than continuing to improving the current way. That involves letting go of what we recognise, taking time to really understand what is going on, and doing something different i.e. sometimes we need to stop trying to do the wrong thing ‘righter’. Otherwise we risk being just the next general marching down that corridor thinking the previous one just did it wrong.

A second blog on the NHS parallels to War Machine can be found here.

*Anderson-Wallace, Blantern & Boydell (2000), Modes of Organising.

** Thanks to Brendan O’Donovan for introducing me to this phrase.

I hope you found this useful.

Contact Nick