02 June 2006
The NHS Institute for Innovation and Improvement's head marries 'lean-thinking' management-speak with NHS values. Sally Gainsbury meets a man of change
You would not necessarily expect the chief executive of an NHS organisation to suggest a meeting in the dark leather and wood panelled surrounds of the Institute of Directors. But then again, you might not expect him to refer to the Department of Health as his 'shareholders'.
One year into his post as chief executive of the new NHS Institute for Innovation and Improvement, Professor Bernard Crump is still enthused about jolting the NHS out of its mixed performance, a subject he will be holding forth on at CIPFA's forthcoming annual conference in Harrogate.
'This whole business of improving services is really exciting,' he tells me, over a hurried lunch of crisps, sandwiches and hyperactive pager. 'It's not something we have to do because the NHS is in difficulty. I believe that if you take on a job in the NHS, you're taking on two jobs. One is the job you've been appointed to, and the second is improving it, so that patients get a better deal.'
His vehicle for doing that – the NHS III – was formed last July out of the NHS Leadership Centre, the NHS University and the NHS Modernisation Agency.
While the National Institute for Clinical Excellence and the Healthcare Commission have clear remits to provide definitive guidance on what treatment methods should be employed, NHS III's role is to support health service bodies by helping them to adopt new methods of working.
It's a role that Crump readily admits can be intangible. 'It isn't easy to define how the institute brings about improvement. It's not as easy as saying “we'll bring out a publication”, there are more subtle ways of bringing about improvement.'
NHS III has been given four 'top priorities': health care associated infections [HCAI], chronic disease care, productivity and access issues, such as waiting times. The work then involves identifying organisations – in and outside of the NHS – which have been successful at tackling those or analogous issues. They are studied and their lessons packaged into what Crump calls 'products', which the institute promotes throughout the NHS.
The institute published its first business plan only four months ago and so NHS-watchers are hesitant to pass judgement without first seeing it in action.
But Crump seems well equipped for making that action happen. Before qualifying as a hospital doctor in 1980, he spent time at McMaster University in Canada – often seen as the birthplace of evidence-based medicine. It was there that he first developed an interest in unpicking assumptions about health care practice, and asking how solidly they were backed up by evidence of real benefits.
After seven years as a hospital doctor and clinical researcher in the West Midlands and London, he retrained in public health. It was during this time that he started to explore business management.
Helping out a business school, Crump 'acted as a kind of go-between for a group of clinicians and people who understood the science of business… I got very interested in learning about how management science could be used to bring about change.'
Not surprisingly, given his driven work schedule, the father of two finds little time for relaxation. 'I don't exercise enough, I have no hobbies and my wife would tell you I work too much,' he says.
She may be right. Crump used to sing in a choir, but even that he relates to his work: 'Singing in a choir is like working in the NHS, in that getting it right depends on all the separate parts being in tune and at the right time and place.'
No doubt it was that dedication to his work that finally got Crump – via ten years in management and chief executive roles in strategic health authorities – to NHS III.
Inauspiciously, NHS III was launched the same month that an unprecedented nine NHS organisations were the subject of Audit Commission Public Interest Reports into spiralling overspends.
PIRs into a further 24 organisations followed and suddenly, as King's Fund chief economist John Appleby has put it, many trusts switched from viewing waiting list targets as their great 'must-do' to achieving financial balance.
This concern for finance surely put the NHS III on the back foot: condemned to play second fiddle to financial 'turnaround' teams, trimming back costs and refocusing trusts on the bare necessities?
Not so, says Crump. 'I'm an optimist. The timing is helpful in many respects. The financial situation means that most organisations need to look at every opportunity to improve things, and that means there's an added incentive for them to take what we're saying seriously.'
Crump agrees that one of the causes of the deficit problem has been the extent and pace of recent NHS improvements – particularly on waiting times. But much of that has been achieved through employing new staff and expanding capacity, he says, meaning there is both the scope and need to look for new ways to improve within budget.
'Growth in resources can't carry on at this kind of rate. It's not sustainable that it grows as quickly as this and we've got to start using some of these methods to be able to continue to see improvement, without having to rely on such large amounts of additional cash.'
So what methods is he talking about? A central tactic is to look at processes afresh and identify where time – in the case of waiting lists – could be saved or, in the case of HCAIs, people's behaviour could be changed. He cites as an example the 'lean thinking' approach borrowed from Toyota cars: 'It's about identifying the steps to a process that really add value to the ultimate outcome.'
Entrusting patients with their own records is one 'lean-thinking' tactic for cutting down the number of times patients need to retell their story to each professional they see and thus move them through the system quicker.
Another NHS III tactic has been to work with product design experts who assess problems from an ergonomic perspective. By observing visitors and staff in hospitals, NHS III designers saw 'things we're blind to', such as what needs to happen to remind people to wash their hands before entering a ward.
Such a business-orientated approach has not been uncontroversial. When the then head of the NHS, Sir Nigel Crisp, told NHS boards last year that they needed to adopt Tesco's marketing techniques to tackle the challenges of payment by results and Patient Choice, some sections of the NHS community denounced such market-speak as evidence of profits replacing patients.
But such resistance doesn't hold Crump back. It turns out he was a key influence behind Crisp's comments. 'I'm not shy to use business vocabulary,' he says. 'Our customers are the NHS, our beneficiaries are the patients and our shareholders are the DoH who provide us with the resources to do our job.'
The last line is delivered with a knowing raised eyebrow. Crump seems to see controversy as something he can harness to promote new ideas.
But he didn't spend time in management school for nothing. 'Human nature means that if someone perceives that somebody who doesn't know their area is telling them what to do, that will be resisted.'
That is why NHS III has invested so much of its energy 'going between' NHS clinicians and managers. And, with a CV like his, it's hard to find areas of the NHS Crump cannot claim expertise in.
Professor Bernard Crump is speaking on NHS reform at the CIPFA conference Thursday, June 15
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