Managing expectations in health services: over-promising and under-delivering?

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'Show me the person who says it will take the most time and cost the most money, and I'll show you the expert', the old saying goes – reformulated recently by the boss of a Marks and Spencer's rival, describing what applicants for the M&S Chief Executive job should have said – ie, that they could deliver, just slowly and painfully and it would get worse before it got better.

Simon English in The Independent said 'this would ensure the candidate didn’t get shortlisted. Boards don’t want to hear this stuff'. We could say the same of the NHS.  My experience as a doctor has taught me to manage expectations honestly and openly. It's irresponsible to offer false hope or empty promises, harming the trust between us and patients. The same principles should apply to those who are advising our challenged health services on transformation.

In March, I told the Health Service Journal that the crisis in emergency care would worsen for the foreseeable future and be slow to resolve, then I blogged that reducing acute capacity with no credible alternative in place could be catastrophic.

Sympathetic respondents wrote 'at last, some straight talking'. I also got hostile mail — exclusively from management consultants. Many are excellent, but some have been well-remunerated by the taxpayer for visiting health economies, modelling dramatic reductions in activity (based on assumptions backed by contestable evidence), dazzlingly presented in a way the NHS can't match, with minimal responsibility for implementation, nor accountability when assumptions prove undeliverable.

In US integrated care models like Kaiser or Veterans Health Administration, sustained improvement took a decade. English beacon services such as Torbay weren't overnight successes, and we have been slow to adopt the lessons. Recent NHS Institute examples in Sheffield and Warwickshire, national improvements in Hip Fracture Care required sustained focus, concerted clinical leadership and time.

Also peddling big gains and quick fixes are some private providers. We don't yet know if handing over chunks of the NHS to contractors really will lead to improvements in quality, efficiency, population outcomes or integration. International comparisons suggest plurality doesn't always deliver. We still see over-claiming by some companies and their lobbyists, headline-grabbing percentages, backed by few data or peer-reviewed scrutiny.

The Department of Health is also a serial offender — driven by the eagerness of ministers and  officials to demonstrate change, announcing policies (some based on flimsy evidence and flawed assumptions), commissioning supporting research, prematurely over-claiming evidence then falling silent once the 'idea of the year' is subjected to independent evaluation. Creating, embedding and sustaining service change takes far longer than the government cycle of introduction and evaluation allows — hence the tendency to 'projectitis and pilotitis'.

Under the last government, we had the push for the introduction of thousands of case-managing community matrons to reduce hospital admissions, despite poor evidence with the DH-funded evaluation showing disappointing results. Also, the results from the Integrated Care Pilots were mixed and the benefits look less impressive when they are rigorously peer reviewed.

The coalition has continued this tradition. Various national QIPP workstreams all set out eye-watering assumptions on reductions in cost or activity with no transparent external scrutiny of their impact. The '3 million lives' push on telehealth and telecare  was accompanied by extended infomercials in the Health Service Journal, with ministers and senior officials prematurely claiming major benefits and urging 'roll-out…now we know that it works'; the Department-sponsored Whole Systems Demonstrator trial has shown modest benefits and no advantages in terms of cost-effectiveness, with the industry's own ‘Remote Care PLC' report casting further doubt on the scale of ambition. The DH 'digital first' plan for electronic patient records is now promising massive savings right after the costly failure of the 'connecting for health' project and with the basis for levels of ambition unclear.

Ultimately, this over-claiming helps nobody. None of us should be passive, cynical or resistant to change. Nor should we be evidence 'purists', failing to look beyond clinical trials, NICE guidelines or Cochrane reviews. But we do need transparent evidence reviewed by experts with no vested interest. We should all strive to improve quality and efficiency, but with unwarranted variation in delivery of evidence-based practice the first focus should be on ensuring that the 'rest are as good as the best'.

My advice would be, see what can be delivered in the best trials, studies or systems, halve the projected effect, double the projected amount of time to achieve it. Accept that once the exciting start-up phase is over, you need sustainability, not new, distracting initiatives. Be a 'service with a memory of service failures'. Remember that benefits for one service or group won't always deliver efficiencies or outcomes across a place or population. Under-promise and over-deliver. You will feel better in the long run and will retain credibility for the next big challenge.


Claire Barry

Mind Yourself
Comment date
18 June 2013
Thank you David, it is very refreshing to read. There is plenty of evidence at a personal and systemic level to suggest that change is most sustainable when incremental and based on changing underlying unhelpful behaviours and practices. Some of the change practices in the NHS are like certain diets, quick fix, ultimately ineffective and often leave a bad smell.

Harry Longman

Chief Executive,
Patient Access Ltd
Comment date
16 June 2013
Thank you David and I hope everyone reads this who cares about evidence informing policy rather than the other way round. And I hope even more that the other lot read it too only more slowly.

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