Ahead of a SU INSIGHTS event on the topic, Fraser Battye, our Head of Policy suggests ways the NHS could make better use of consultancy support.
Human life is short and precious. We must try to spend our time well. That’s why – years after the event – I'm still traumatised by a workshop run by one of the big-name management consultancies.
The aim of the session was to help leaders of Integrated Care Systems (ICS) understand what was required of them. Interested in the topic, and keen to see how the big firms run things, I went along.
I regret it. I began to wish my life away quite early on. But I was praying for the end to come when the facilitator – a partner in the firm – led the following exercise.
Participants were asked to ‘score your ICS out of 10’. We went round the room, one by one, for about 25 people. Everybody gave a rating. These numbers were written down and added up.
The facilitator paused, and touched his chin, before repeating the exercise - but this time asking for a score out of 10 for ‘where you want your ICS to be’.
Results were compared. The second number was higher than the first. Using this insight, the facilitator noted that there ‘seems to be room for improvement’, before inviting another of the firm’s partners to comment further.
Precious human life slipped slowly by…
A related, but funnier, example comes a similar workshop where NHS leaders were asked to ‘rate themselves out of five for their humility’. (A moment’s thought provides the punchline).
Serious examples can be given. The Strategy Unit has seen multiple analytical exercises, conducted by consultancies, where decision makers couldn’t possibly know how robust the results were. Decisions about allocating and withdrawing scarce NHS resources using analysis where the underlying assumptions, data and code were hidden from view.
‘Commercial in confidence’. Three words that can leave decision makers shooting in the dark.
This is not a ‘consultants bad’ argument. There are occasionally excellent reasons for using consultancy support; and I've worked with many utterly scrupulous and highly public-minded consultants.
Nor is my point ‘public good, private bad’. Professionally, I was born and raised in the private sector. I would happily return to it in the future.
Instead, I’m suggesting that there are ways of getting far better value for money when using specialist support. This should be fairly easy for the NHS to achieve.
Will it?
Hope springs eternal. And three sources seem especially encouraging.
The first source is political. The Labour manifesto referred to ‘excessive use of consultants’ as a source of waste. Karin Smyth used to work in the NHS; she is now a Minister. Noting that the Department of Health and Social Care’s spent £600 million on consultants in 2023 - Smyth has talked of the need to break this ‘expensive addiction'.
The second source of hope is empirical. Professor Andrew Sturdy (University of Bristol) and colleagues have amassed an evidence base – from across different sectors - that use of management consultants can be self-defeating.
For example, one summary of this work suggests that greater use of external consultants in the NHS increases inefficiency. And that – despite these negative effects – high use leads to even higher use. Talk of addiction seems apt.
The third source relates to the second. In their recent publication, Professor Sturdy and colleagues conclude that:
“…the appetite for less market-based and more socially responsible approaches grows.”
They then note growing interest in public sector organisations developing their own ‘internal consultancy’ capabilities. Professor Sturdy and colleagues are now comparing outcomes from support provided by ‘internal’ and ‘external’ consultancies. Results will be shared at an SU INSIGHTS on March 19th.
‘Internal consultancy’ is not a hypothetical possibility. There are a growing number of NHS teams already using this model. Many are housed within Commissioning Support Units; all offer specialist support - in health economics, large-scale change, service transformation, digital technologies (etc) - for other NHS organisations to draw upon.
The example I know best is the Strategy Unit. I joined from the private sector just under a decade ago, wondering whether an NHS team could operate on a consultancy model.
We remain a work in progress - a work full of flaws and wrinkles (mostly mine) - but I've seen that the answer is ‘yes’.
One way we use the ‘internal consultancy’ model to add value is through open source analysis. We share as much of our work as we can, freely and publicly.
Anyone can see how good (or otherwise) our analytical work is. This is not easy or comfortable: everyone makes mistakes; ours will be there for all to see. But, because our incentives are to uphold a reputation for quality, this sharpens what we do.
This may sound nerdish and niche. And yet it has wider implications. Open source analysis flies in the face of commercial incentives (‘build once, sell many times’). If it became standard, the opaque practices of many external consultancies would come to an end.
I'm convinced this is a route to higher quality work and greater public value. Making this wide-spread relies upon some important changes in behaviour. Our approach has been encouraged and nurtured by collaboration with some enlightened customers.
It is entirely within NHS control to create ‘less market-based and more socially responsible approaches’. Political will sets the direction; internal consultancies pave the route; ‘open by default’ working practices get us where we need to go.
As for scoring yourself out of ten in expensive workshops…presumably we can all agree to just not do this?
