Sustainability through delivery — how changing expectations kept waiting times low in the NHS
The government, NHS employees, the public, and the press all came to expect both a higher level of service and to know that it could be delivered.
In June 2001, around 46,000 patients in the UK were waiting over a year for operations.
The newly created Prime Minister’s Delivery Unit (PMDU) was tasked to work with the Department of Health and front line staff to reduce these numbers. A “war on waiting” was declared. The PMDU’s relentless focus on delivery initially proved controversial, with critics attacking the “targets and terror”.
However, the results began to speak for themselves. Between June 2001 and June 2002 the number of people waiting more than a year for treatment fell from around 46,000 to just over 20,000. By March 2003, the number had fallen to just a few hundred. Progress continued, and by the 2010 general election waiting times across many areas had reached historic lows.
However, in 2010 the PMDU was abolished. With the loss of the unit, waiting times slowly began to increase again. By the summer of 2015 the number of people waiting over a year had risen to 6,118, the highest for seven years. Those who said that delivery was not sustainable were being proved right.
Except then the waiting list became a crisis. The press attacked the government for leaving people “languishing on NHS waiting lists”, with commentators accusing hospital managers of “waiting for people to die”. This was despite the fact that at the time, the waiting list was just 13% of what had been seen in 2001.
In 2001, some people felt that a waiting list of 46,000 was inevitable. In 2002, many celebrated a reduction to 20,000. Yet in 2015, a list of 6,000 triggered a crisis.
In reality, the long term legacy of the PMDU was not just a reduction in the waiting list, but a change in people’s expectations of what should be delivered. The government, NHS employees, the public, and the press all came to expect both a higher level of service and to know that it could be delivered.
As a result, the Delivery Unit’s work proved sustainable, not because of the approaches themselves, but because of the change in expectations they caused. That proved the key to ensuring a long-term change in performance.
Governments and delivery teams can take a range of other actions to ensure sustainability. They need to:
- Ensure executive focus to sustain momentum. The PMDU had direct communication, personal involvement, and central authority from the executive to get things done. Blair’s later advice to Cameron was that “If the Prime Minister wants to ensure successful delivery, he personally will have to pay attention to it.”
- Institutionalise delivery by creating dedicated bodies. The PMDU’s formal role at the heart of government was central to its ability to sustain delivery. The PMDU-model gained a global reputation, and has been successfully emulated in United States, Malaysia, Brazil and Pakistan.
- Prioritize. Ruthlessly. Trying to do everything at once inevitably tangles delivery, making reforms falter and become unsustainable. It was largely “by prioritizing waiting lists and managing it via the PMDU” that Blair felt progress happened.
- Work with teams, not against them. Departments came to see the PMDU as “genuinely part of the team trying to solve things”, compared to “every other central unit that just questions”. By working alongside teams “like partners”, the PMDU created good working relationships and fostered a focus on long-term delivery.
- Experiment with a number of different initiatives to see what works. It is “better to have several small failures than one big one”, according to David Helpern, former Chief Analyst in Blair’s Strategy Unit. Big failures kill momentum and appetite for long-term reform. Driving a number of good initiatives can insulate against this.
- Produce performance data to enable central control, pressure the bureaucracy to deliver, and publically celebrate progress. Seeing something working is the most powerful force for sustainability.
- Develop and embed new routines to establish continuity, create common vocabularies, and institutionalize delivery-orientated cultures that embody reform.
- Ensure delivery efforts build the systems, capabilities and skills needed to deliver the results in a wide range of officials and people, so that there is capacity to sustain results in the long term.
- Publish performance data to engage the public, get them onside and increase their perception of progress. Sometimes public attitude can be as important as the actual numbers, and keeping attitudes positive can prevent crises from derailing reforms later on.
- Have the courage and belief to keep going, deflecting initial criticism and not being overly concerned if immediate results aren’t that great or if there’s an initial “implementation dip”. Use the data to keep a track of progress and ensure focus on the long-term goals.
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