Best possible value – Diagnostic workshop · - Matthew Cripps - Mark Mansfield • Delivery group members - Caroline Clarke - Jennifer Howells - Ed Kessler - Ros Francke - Tim Welch

This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent

Best Possible Value – Diagnostic Survey Results

This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent 2Best possible value Dia ... op v04LON

Survey/interviews: Context

PURPOSE IS TO… WHAT IT IS

WHAT IT’S NOT

• Give a high level assessment of the

health of decision-making across the NHS

• Help identify the most important issues to

tackle in striving for more effective

decisions

• Provide input into which decisions to

focus on

• Guide prioritisation of actions on specific

decisions and broader organisation

enablers

• Reflection of personal opinions

• Drawn from a sample of finance and non-

finance people within different

organisations

• Starting point that helps focus energy and

provides a platform for discussion

• Exhaustive set of issues and opinions

• The ‘gospel truth’ on strengths and

weaknesses

• The final answer


Executive Summary

*Decision effectiveness scores percentiles are relative to Bain benchmark database

• Over 150 people responded to the ‘best possible value’ survey

- 65% Finance/35% non-Finance

- Good mix of commissioning/provisions; good mix of regions

• NHS benchmarks itself below average vs. our global database on decision effectiveness

- 34th percentile* out of 100

- Particularly low in speed

• Considering the drivers of decision effectiveness, some clear strengths on which to build

- Passionate employees committed to the NHS

- Reasonable alignment around the importance of ‘best possible value’ in considering decisions

- Finance seen to have a seat at the table in key decisions related to ‘best possible value’, and the capabilities

to make a difference

• A number of areas require focus to improve ‘best possible value’ in decisions

- Lack of a clear and agreed measure of ‘value’

- Given the structural complexity of the NHS, too many people involved in decisions, with roles not entirely

clear; especially for decisions which multi-party stakeholders

- Decision processes tortuous and not sufficiently informed by the right information

- Behaviours don’t always support decisions rooted in ‘best possible value’

• Issues will need to be tackled within Finance, but also beyond

• NHS employees see a strong need for organisational change to support ‘best possible value’,

both across the NHS and within their own organisations

WIP


We surveyed employees across all dimensions of the organisation,

supported by ~20 in-depth interviews

Source: Client diagnostic (n=153)

WIP

SURVEY INTERVIEWS

• Finance Leadership Council

- Paul Baumann

- Richard Douglas

- Bob Alexander

- Stephen Hay

• Delivery group heads

- Peter Ridley

- Mark Ash

- Matthew Cripps

- Mark Mansfield

• Delivery group members

- Caroline Clarke

- Jennifer Howells

- Ed Kessler

- Ros Francke

- Tim Welch

- John Yarnold

• Additional interviewees

- Jan Fowler

- Sanjay Agrawal

- Chris Mimnagh

- Muir Grey

- Greg Fell


NHS decision effectiveness is below average

NHS:34th percentile

DECISION EFFECTIVENESS GROUPS

(QUALITY X SPEED X YIELD – EFFORT)

Best/81-100th percentile

61-80th percentile

41-60th percentile

21-40th percentile

Worst/1-20th percentile

WIP

Source: Bain decision and org effectiveness survey Jan 2013 (n=1001)


Quality Speed EffortYieldx -x“How often do you choose the right

course of action?”

“How often do you execute decisions as

intended?”

“How quickly do you make decisions vs.

stakeholder expectations?”

“Do you put the right amount of effort into making & executing

decisions?”

Decision Effectiveness Benchmarks

Slo

wer

than…

Faste

r th

an…

On p

ar

with…

NHS performs below average on each category, particularly on

speed

High decision effectiveness range = top quintile of decision effectiveness scores; Low = bottom quintile; Mid = all otherSource: Bain decision and org effectiveness survey Jan 2013 (n=1001)

“lower is

better”

WIP


“Diagnostic on a page”

Aim

Deliver value

• Organisation is clear about and aligned on importance of delivering value

• Lack of clarity on how value should be measured

Structure Roles Process DataTools

• Complex NHS

structure means

lots of people are

included

• Data and

information not

readily available

to be fed into

decisions

• Have some tools

to be able to

assess value

• Lack guide on

how to apply

tools to deliver

BPV and how to

run the process

to ensure right

people

involved, inputs

captured and

data used

• Decision framing

and criteria ok

• Decision-making

process within

organisations

works ok

• Decision-

making process

across

organisations is

broken

• Clarity on

purpose of voice

e.g. clinical,

financial

• Lack of clarity

on decision-

making roles

e.g. input vs.

decide

• Lack of clarity

on roles of

various NHS

entities in multi-

party decisions

• Speed of decision making is poor and quality, yield and effort are average

Decision

making

Outcome

Primary focus:

most significant

areas for

development

and/or high

ability to

change within

this project

Secondary focus:

less significant

areas of

development and

/ or limited ability

to change within

this project (e.g.

NHS super-

structure)

Key

• People passionate about NHS, willing to go the extra mile

• Behaviours not consistently supportive of effective decisions

People

• Good capabilities

to meet today’s

needs; and want

to do right thing

• Lack capabilities

for future

challenges

Behaviours


Decision effectiveness is worse for the NHS as a whole; it’s seen

as better within specific organisations

Note: NAs excluded; 1=Strongly disagree, 2=Disagree, 3=Agree, 4=Strongly agree; High performer = top quintile “decision effectiveness” scoresSource: Bain decision and org effectiveness database (Jan 2013) n=1001; NHS diagnostic (n=153)

Strength: ≥ avg + 0.2

Excellent: ≥High perf. avg

Concern: ≤ avg – 0.2

WIP


Context around what drives value

Clear accountability for critical decisions

Winning culture and workplace behaviour

People equipped with right skills & capabilities

Communication and alignment

Structure that enables key decisions

Right information, right form, right time

Cohesive leadership

Effective decision processes

2 3 4StrongAverageWeak1

Across drivers of decision effectiveness, NHS performs particularly

strongly on culture but low on clarity and structure

Source: Bain decision and org effectiveness database (Jan 2013) n=1001 ; NHS diagnostic (n=153)

High decision effectiveness range n=324Low/Mid decision effectiveness range n=677NHS n=153

Co

nte

xt

&A

lig

nm

en

tA

cco

un

tab

ilit

y&

Str

uctu

re

Pro

cesses &

In

form

ati

on

Lead

ersh

ip &

beh

avio

urs

Skil

ls &

Cap

ab

i-li

ties

To

ols

&T

ech

Tools and technology align with needs

WIP


Top scores: leadership and behaviours

Accountabilities & Structure

Leadership &Behaviours

Skills &Capabilities

Scoring: 1=Strongly disagree, 2=Disagree more than agree, 3=Agree more than disagree, 4=Strongly agreeSource: Bain decision and org effectiveness database (Jan 2013) n=1001; NHS diagnostic (n=153)

WIP

Context & alignmentAccountabilities & structuresProcesses & informationTools & technologySkills & capabilitiesLeadership & behaviours


Bottom scores: accountabilities and processes

Scoring: 1=Strongly disagree, 2=Disagree more than agree, 3=Agree more than disagree, 4=Strongly agreeSource: Bain decision and org effectiveness database (Jan 2013) n=1001; NHS diagnostic (n=153)

WIP

Accountabilities & structure

Processes &information

Context &alignment

Context & alignmentAccountabilities & structuresProcesses & informationTools & technologySkills & capabilitiesLeadership & behaviours


Source: Bain decision and org effectiveness database Jan 2013 (n=225); NHS diagnostic (n=153)

HOW LIKELY WOULD YOU BE TO RECOMMEND THE NHS

AS A PLACE TO WORK TO A FRIEND OR RELATIVE?

%

Promoters

minus

%

Detractors

Extremely

likely

Extremely

unlikely

0-6

7-8

9-10

0-6

NET PROMOTER SCORE (NPS)

CALCULATION

Employee engagement is below average relative to benchmarks

Net Promoter Score (NPS)

®Net Promoter, Net Promoter system and NPS are registered trademarks of Bain & Company, Inc., Satmetrix Systems, Inc. and Fred Reichheld

WIP


Uniform belief that significant change throughout the NHS needs

to occur to support BPV




Concern: ≤ avg – 0.2

WIP


Winners align key elements

• Clarity on priorities and principles

• Communication and alignment throughout the

organisation

• Robust decision processes linked to effective

business processes

• Key metrics and information–right place, right

time

• Clear roles for critical decisions

• Simple, cost-effective structure that supports

value creation

• Right people in right jobs - will & skill

• Objectives & incentives focused on performance

• Cohesive leadership team living the right

behaviors

• Winning culture, with individuals who personally

engage

Tools &technology

Critical decisions

• Efficient tools

• Technology that enables decisions


Context & alignment: clear need for BPV, but BPV

measurement is lacking, and non-finance is not aligned


WIPStrength: ≥ avg + 0.2


Concern: ≤ avg – 0.2INTERVIEW QUOTES

“We need clarity on what value means, it doesn’t currently exist – people have their own view”

“We lack a good narrativearound why value is important and what it means”

“Need to get clarity and alignment around what objectives are, what outcomes are desired”


Accountability & structure: Finance understand their role

but cross-organisation decision roles are not clear





“Budget holder, initiator, clinician, service manager are recognised titles – but decision roles are less well defined”

“Within an organisation roles and accountability are clear or can easily be made so –across organisations there’s a lack of clarity”

“Finance needs to take a leadership role as owners and appliers of the investment process, it needs to have bravery to have absolute rigour and force robustness of decision-making on hard evidence”


Processes & information: decision criteria considered clear,

but lack of info and cross-organisation processes


WIP




“The length of decision-making is an issue – it’s taken 8 years to decide on a new hospital complex and a decision still hasn’t been reached”

“We simply lack the information to be able to make a decision – I had 69 protocols to approve but no data to be able to say which patient admittances would be reduced”

“We have too many committees with decisions getting tied up in levels of approval”


Tools & technology: BPV is not consistently well supported

by existing tools and technology





Finance need the tools and the confidence that comes with them to be consistently rigorous and robust in analysis and communication”

“We have no toolkits that are widely deployed for decision structuring or decision evaluation”

“We need a knowledge management system to share experiences for others to learn from”


Skills & capabilities: people are well placed to incorporate

BPV in finance, less so outside of finance





“We’re bringing in bright people with the ability to work in the way we need. But then we get them in and teach them not to use their skills”

“If finance sits in their finance office without getting close to where care is delivered, they will have technical expertise but not be able to apply it to best value”

“Incentives and objectives could be re-aligned; surgeons want to operate and the service line may be very lucrative but 50% of operations may have no benefit – the objective should be no useless knee surgeries”


Leadership & culture: employees strongly engaged, culture

not a major barrier to BPV





“No one single finance person has the ability to bring their “tribe” with them. We need a leadership council approach – a ‘concordat’ between what people perceive as senior finance leaders”

“Our biggest issue is protecting individual organisational interests, instead of thinking about value broadly across a locality”

“No culture of making these decisions in a value based way”


THE DECISION STYLE IS…

TYPICAL DECISION

STYLES…

Desire for less directive, and more participative

decision making


• Directive:

- Decision making authority rests

exclusively with one person, who

issues directives that are

expected to be followed

• Democratic:

- Decisions are reached based on

vote (e.g. majority rules)

- Dissenting views are expected

to support the final decision

• Consensus-driven:

- Decisions are reached when all

involved reach agreement

• Participative:

- Single-point accountability for a

decision, with input taken from

those with relevant knowledge

and expertise

- Once a decision is made, all are

expected to support it

WIP

In the NHS as a wholeIn your organisation in the NHS


TOP 2-3 ACTIONS: WITHIN FINANCE

Top priority actions: Tools, information and closer partnering

between finance and clinicians


WIPSURVEY INPUT

TOP 2-3 ACTIONS: FOR NON-FINANCE

“Some real tools to

help us evaluate best

value balancing

quality and finance”

“Can we have information

in a way we can

understand and is

relevant? And timely?”

“Non-finance engaging finance

early in change processes

because they value their

support and input rather than

'because they have to”

“Training and tools

sponsored by finance

for other teams to use”

Documents

Best possible value – Diagnostic workshop · - Matthew Cripps - Mark Mansfield • Delivery group members - Caroline Clarke - Jennifer Howells - Ed Kessler - Ros Francke - Tim Welch