Posted by: Jonathan Shapiro24 September 2013
I don’t usually have much time for self help books, and much of Stephen Covey’s ‘Seven Habits of Highly Effective People’ is fairly self-evident; it’s not exactly rocket science.
However, his famous ‘urgent/important’ matrix does come to mind when looking at the way in which the NHS operates; indeed, the matrix seems to apply to most public services. It is a pictorial diagram, and so not easy to describe, but in essence it divides life’s tasks into four quadrants. These range from those that are not urgent and not important, and should thus be given extremely low priority, like washing the car (pretty obvious really), to those that are both urgent and important, like putting out the chip pan fire, that need to be completed as soon as possible (not too difficult to understand either).
It’s the ones in-between that are more interesting: Covey makes the point that urgency tends to trump importance, so that tasks that are urgent but unimportant are given disproportionate priority over those that are important but not urgent, which are all too often ignored. It may be so in our personal lives, where doing things for the sake of appearances are all too often given priority over the things that actually need to get done, and it certainly applies to life in the NHS.
Thus for example, reporting the handling of a patient’s complaint seems to take precedence over the handling of the complaint itself, just as when we were children, keeping our rooms tidy was seen as being more important than playing the interesting games that would get them in a mess.
Much of this dissonance comes from the issue of power and agenda setting. When we were children, it was our parents who did both, and for CCGs, it seems to be almost everyone else: NHS England, the area team as their local incarnation, even the local acute Trusts seem to be able to impose their priorities onto the new clinical commissioners. This has meant that many of the CCGs have been spending the last six months adhering to due process and meeting externally imposed targets - all of which are urgent - at the expense of maturing as commissioners, and developing their working relationships - all of which are important.
The imbalance of power that leads to this distortion of priorities underpins many relationships (personal as well as in business), but is particularly pronounced in the public sector, where political pressures (often manifested in the media) come to bear as well as financial ones. It is a truism that ‘he who pays the piper calls the tune,’ but when he who pays the piper also lays down the law and feels the need to respond to populist prejudices, then the piper is bound to find it difficult to produce new tunes or even refine the old ones.
In NHS terms, we can see the consequences of this phenomenon in a number of ways; for many CCGs, the urgent daily pressure to meet an endless series of operational targets (mainly financial, but also based on clinical and administrative activity) has subsumed the important task of developing a longer term sustainable strategic approach to the delivery of services. The constant need to tick all the short term boxes puts at risk the underlying purpose of CCGs, which is to get to grips with the commissioning agenda: rationalising the delivery of health services so that the health service has a chance of coping with the pressures of future demand.
The external pressures are also constraining many CCGs from prioritising (in terms of both time and money) their own development; many have set up novel management arrangements for their senior teams that need developing and honing. Perhaps more importantly, all need to work with their members to change the whole nature of the relationships between individual GP practices and their CCG, so that they fulfil the promise of marrying local implementation for their individual patients with more strategic planning for entire populations.
Of course, it’s easy to criticize other people’s policies, and the reality is that political and financial imperatives have to be met. So how can the important match the urgent? From my perspective, the answer is for the Centre (NHS England and the area teams) to forge their links with the CCGs based less on micromanaged targets, and more on agreed outcomes. Once a CCG has agreed to deliver some broad, population-based outcome objectives with an appropriate budget, then it should be left to the CCG to manage its operational delivery without its ‘parents’ looking over its shoulder all the time, and telling it to ‘go and tidy your room.’
Whether as maturing teenagers or NHS agencies, the key is to feel that we are acting on what we feel is important, not what we are told by others. If the NHS perpetuates the current situation, where CCGs are all doing what others feel to be urgent, then the future of the new system will be short lived indeed; however, if CCGs are allowed to decide their own set of urgent and important priorities within a broad national framework (and budget), then the system will do what was intended: better care, more locally and efficiently delivered, on a more sustainable basis.
Dr Jonathan Shapiro is an a former GP with wide experience in clinical, managerial, and academic roles. He works with policy makers, organisations and individuals to develop effective, sustainable systems with integrated clinical and managerial functions You can email Dr Shapiro on firstname.lastname@example.org.