Post-mortems needed to learn from failed healthcare policies

I never did get the hang of pathology. As a medical student, I soon realised that gazing through a microscope at cross-sections of body parts was an entirely futile activity. Whether I was looking at brain or kidney, whether it was diseased or healthy, everything looked like incomprehensible examples of abstract modern art.

When a lecturer once asked me to describe a microscope slide of a section of bowel, the only answer I could provide was a hesitant, “It’s pink”, which induced such mocking laughter from my fellow students that he mercifully picked on them instead, with the challenge of “so can you do any better?”. They could. It would be hard not to.

But the one pathological activity that made sense was the post-mortem. Examining the body to see what had really happened, as opposed to what we thought had probably happened, seemed both a logical, and frequently humbling, activity.

Cold hard facts

There was no running away from the factual, rather than the theoretical. The cancer, the blood clot, the obstructed artery – they were either there, or they weren’t. However distinguished the doctor who had made the diagnosis might have been, there was no disputing the cold hard facts when he or she was shown to have been entirely wrong. Or, occasionally, right.

Examining what has happened after something goes wrong is an entirely necessary and desirable source of learning. Which makes it all the more puzzling that discussions about health and care policy so rarely seem to ask the obvious question: why did the previous policy fail?

I have lost touch with how many reorganisations of the NHS there have been during my career. At the very least, there have been Executive Councils, FPCs, AHAs, RHAs, FHSAs, PCGs, PCTs, CCGs, and now we are knee-deep in ICBs.

Waffle generator

At the launch of every new organisational structure there will be a presentation with slides showing how “this time, it will be different”.

And every single presentation will use a random waffle generator to boast about “increased efficiency”, and “quality” and “patient centredness”. But they rarely do a post-mortem. They never ask what went wrong last time. And so, we never learn.

Over the past few months, I have been privileged to join all manner of seminars and discussion groups about the future of the NHS. In these, wonderfully passionate and committed people offer interesting and well-argued solutions. But they rarely look back. And this is such a missed opportunity.

Reveal potential pitfalls

At Kaleidoscope Health and Care, we are fans of the “pre-mortem”. When discussing work with clients, such as a new strategy, we often ask them to imagine five years in the future, and consider the question, “If the work turns out to have been a failure, why might that have happened?”

It’s a technique that reveals all manner of potential pitfalls, and allows these to be addressed in advance, rather than as post-mortem damage limitation. And it is usually straightforward human factors, rather than complex organisational issues, that turn out to be the problem.

The period between now and the next election will be packed with well-meaning advice for the next government about how to fix health and care. If we want the next reorganisation to be more effective than every other previous attempt, we need to ask some simple questions about failure. And then we just might succeed.