Managing Without Miracles

Reforming health care in the U.K. took clear thinking, determination and hard work.
March 4, 2009
By John D. Donahue  |  Contributor
John D. Donahue is a GOVERNING contributor. He is the Raymond Vernon Lecturer in Public Policy, faculty chair of the Harvard Kennedy School Case Program and the SLATE teaching initiative.

Improving government's performance is inherently hard. Resources are usually scarce, dueling definitions of "better" make deadlock a constant risk, and even the most perverse status quo has its defenders. This makes every success, however incomplete or ephemeral, worth celebrating. Here's one to savor -- or maybe "savour," since it comes from the U.K.

Last month, a faculty colleague and I headed to London with 22 terrific students, to inaugurate Harvard's new joint degree in business and government. Our goal was to learn a little about health-care management reforms in Britain, to match with a week's study of parallel efforts in the U.S. None of us were true health-care experts; we just wanted to immerse ourselves in two different ways of dealing with a big, complicated governance challenge.

England's National Health Service was a royal mess in Tony Blair's first term. The goal, often elusive, was for emergency-room patients to be seen within 12 hours. And if a patient got a necessary hospital procedure within a year and a half, it was considered a success. More than 1.3 million people were waiting for treatment, often in pain, and sometimes fatally too long. The toll of suffering and avoidable deaths was too much even for the English, who make stoicism in the face of privation a point of pride. Bad medical care became a white-hot campaign issue, and Blair was re-elected on a promise to fix the system.

The first phase went badly. Too many goals meant diluted efforts. The prospect of bigger and bigger budgets undermined concern for efficiency. More of the same -- even much more of the same -- wasn't going to bring about the performance transformation that citizens expected. By 2003, the reform campaign seemed badly off track, and Blair realized he was going to have to invest some serious political and human capital to rescue it. Blair and his health team revamped the sweeping reform plan into a laser-like focus on reducing waiting times.

And they did it. By 2006, most emergency-room patients were either treated and sent home, or admitted to the hospital, within four hours. The targets for non-emergency care -- a wait of less than six months for inpatient care and 13 weeks for outpatient care -- were met or exceeded. Warnings that "faster" meant "worse" turned out to be bogus. The waiting time for health care essentially vanished as a political issue.

How did they pull it off? Three central players told the tale to my students: Paul Corrigan, Blair's main health advisor; Adrian Masters, the health-care guru within the Prime Minister's Delivery Unit; and, Duncan Selbie, in charge of performance management at the Department of Health. There was no magic to their success. It was mostly due to what any experienced manager would anticipate. Keep things simple. Be disciplined about setting just a few goals and sticking to them. Pick relevant indicators, measure them honestly and focus on them relentlessly. Forge a lockstep alignment between the priorities the prime minister announces on television and the incentives doctors and administrators encounter in the village clinic. Make sure the resources are commensurate with the mission. Communicate the same message, in the same words, until you can't stand it -- which is just when it will first be heard. Expect everything to take twice the time and effort it ought to take. Brace for setbacks. Never give up.

Just like any other public-management success, in other words, this primarily came down to a bunch of smart and determined people dealing with each obstacle, one by one, until the job was done. No miracles. But it was still a little thrilling to watch my students listen to the war stories, picking up lessons about the satisfaction of accomplishing something big and the fun of working with a first-rate team.

Let's not kid ourselves: Performance still isn't perfect at the National Health Service. It took a ton of money, not just management mojo, to get this done. Some people think the British approach to health care is fundamentally unsound. Fair enough. It's still a tribute to our craft that clear thinking and hard work were able to make the system perform better -- lots better -- for the sick and injured of England.