Our vision: to transform access to medical care.

Marginal gains – don’t get out of bed

Not long ago a local NHS manager told me they were pursuing the Dave Brailsford model of lots of tiny little improvements – he the cycling supremo who let us bring home so much gold from the Olympics.  I thought it a one off comment, but a blog of Roy Lilley’s this week called it an NHS fad.  Like him, I’ve no doubt it’s a misguided one.

Cycling is a beautiful thing, highly sophisticated and at the Olympic level, a more streamlined cut of sideburn can make the difference between podium places.  But the NHS is not a competitive sport, it’s an operational business and if everyone had a rough imitation of the current best model, we’d all be miles better off.

The problem with thinking about marginal gains when the system is broken is that you miss the biggest opportunities.  Attention, that very limited resource, is in the wrong place.

“Improvement is not enough.  We need transformation.”  W Edwards Deming said it thirty years ago.

“If I had asked people what they wanted, they would have said a faster horse.”  Henry Ford said it, a century ago.

If he had listened, we’d have carbon fibre wagon wheels by now.

Gee up, Dobbin.

Harry Longman

PS.  You’ll have noticed all the noise about STPs.  They have transformation in the title, of course.  But they are really about money, and I’m afraid that’s no way to achieve transformation.  Cost cuttting, yes, restructuring, yes, noise, aplenty.  What we need is different thinking, starting with patient demand.

PPS.  “Marginal gains secured by new care models…” was the title of a King’s Fund blog this week.  Marginal gains?  Remember, the new care models were the flagship policy of the Five Year Forward View.  Two years in, untold £millions spent, and they are bigging up “marginal gains”???  Please don’t get out of bed.  If it was working they would have something more to shout about

4 responses to “Marginal gains – don’t get out of bed”

  1. David Hanlon says:

    Your call to arms for transformation is well stated, but in a complex system there is need for both incremental improvement and transformation; the challenge is to know which is the appropriate step and what is within your power.

    Demming was also a champion of constant and experimental improvement.
    Clear and rational planning is required.

    Sometimes a transformation in work practice is required to make an incremental improvement, to step up to the next level. But radical transformation also carries risk. Risk that you don’t deliver the transformation; risk that the transformation doesn’t deliver the improvement. It might even make things worse.

    The point is that we can all make incremental improvements (that’s the key word, not just changes) and they are low risk, they do need to be encouraged.
    Equally the right transformation is required, but this is generally not in the gift of the troops on the ground, we need to deal with what we can.

    It’s not an “either/ or” situation, we need both.

    • Harry Longman says:

      Agree David that both have their place. But transformation needs to come first for improvement to be worthwhile. And it requires leadership to make that happen.

      • Harry Longman says:

        I forget whether it was Deming or someone else who said, “There’s nothing more wasteful than doing more efficiently that which should not be done at all.”

  2. As the first person to bring the Marginal Gains methodology to the NHS I am somewhat biased.

    As with all transferable skills it has its limitations. What it does have however is a good track record (pun intended) in helping managers deal with increasing amounts of pressure. alan@rootedtraining.com

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