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Editor’s blog Friday 11th December 2009: New DH policy document – inspired by Jim Collins or Juan Collins?

Time for a medicines use review, clearly: they’re having visions again in the DH.

The first chapter of new policy document The NHS 2010-2015: from good to great - preventative, patient-centred, productive is called ‘Sustaining the vision’.

Just what we need: a compendium of mission-statement-speak.

Dr Jim will see you now
The document’s title references the best-known book by Jim Collins. This creates an intriguing dynamic tension with regard to the timescale in question (2010-2015).

If you follow the link above, you will see that Collins states, “on average, it took four years for the good-to-great companies to crystallize their Hedgehog Concepts. It was an inherently iterative process—consisting of piercing questions, vigorous debate, resolute action, and autopsies without blame—a cycle repeated over and over by the right people, infused with the brutal facts, and guided by the three circles”.

And that is just the concept – the idea bit. Which suggests that moving the NHS from good to great in five years could be a bit of a stretch.

The Collins three-ring circles
What, then, are Collins’ circles? He describes them as “three intersecting circles that represent three pivotal questions: What can we be the best in the world at? (And equally important—what can we not be the best at?) What is the economic denominator that best drives our economic engine (profit or cash flow per “x”)? And what are our core people deeply passionate about?”

Read Collins’ cited exemplar companies: some stories are sobering. Kimberly-Clark’s turnaround took 25 years. The NHS has rather less than that.

Collins’ propositions centre strongly on leadership. While leadership is an important quality, and much good work has been done by Dr Neil Goodwin of Goodwin Hannah on its role in the NHS, the criticism of Collins’ theories of Robert Sutton, author of the magnificent The No Asshole Rule, is not unreasonable. Sutton decries Colins’ fetishising faith in leadership.

Sutton’s other books, apart from the stunningly-titled opus above, are also worth investigation. Hard Facts, Dangerous Half-Truths, and Total Nonsense: Profiting from Evidence-Based Management (written with Jeffrey Pfeffer) is a must-read, as is The Knowing-Doing Gap.

At the same time, Collins has a radical perspective for a US management thinker. He recently told journalist Peter Hossli that “bonuses don’t lead to higher performance. They just lead to higher-paid executives … There’s basically no relationship between how much executives are paid, how they’re paid, and how they perform …  There was no evidence that there was a relationship between executive compensation and performance”.

The ‘good to great’ NHS
The Sutton / Pfeffer school of thought - that distributed leadership and a culture of respect are keys to success – chimes with more of my experience of good organisations than the Collins vision of crucial single leaders. Maybe this is a reflection of the organisations I’ve worked for and with to date.

So, will we see a ‘good to great’ NHS with the tariff stuck for four years; pay rises capped at 1 %; front-line spending protected to 2013; and another half-penny added onto the existing half-penny rise scheduled for April 2011? Not to mention making 10% of acute income contingent on patient satisfaction?


It’s not all about the money, of course, although the service has displayed shameful slowness to realise what was coming down the track with the credit crunch and recession.

Even to consider this is to make some heroic assumptions: that Labour can win at the next election (unlikely); and that policy remains fixed (which, given recent events around contestability and the divesting of provision, is quite an ask).

Meanwhile, we have much fun ahead with the promise “For 2011/12 onwards, there needs to be significant reform to QOF to deliver improvements in quality and efficiency. This is likely to mean raising performance thresholds and retiring indicators that have limited cost-effectiveness to make way for more stretching quality indicators”. David Nicholson seems to be channeling Fairytale Of New York - “Happy Christmas, Hamish Meldrum, pray God it’s our last”.

Oh, and they still haven’t worked out what freedoms to give good commissioners. It’ll be April, and my bet's on the first ... “We will offer freedoms and incentives to high-performing commissioners and ensure that the best commissioners are at the leading edge of the drive to improve quality and productivity. A programme for high performers will be in place by April 2010.”

And FTs are to take over the world: “We will encourage high-performing NHS foundation trusts to expand their services. This may mean foundation trusts based in one area providing both acute and community services in other areas … we will seek to remove the barriers that NHS foundation trusts face in expanding their services. Foundation trusts will be able to be considered to run primary medical services, within appropriate frameworks”.

And the DH “will look again at the reconfiguration process to see whether it can be further simplified”. Which on previous form, means nobody will be closing any provider anywhere, ever.

Just Juan damn thing after another
This could be more Juan Collins than Jim Collins.

Here's looking at you, kid.