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Doing less and achieving more

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I want to share a few thoughts as I hand over the baton to a new generation of leaders in NHS Alliance and return back to the Primary Care Foundation. The best example of offering advice to a new generation is the one and only no.1 hit with a clear and unambiguous public health message – Baz Luhrmann’s 1999 ‘Sunscreen Song’ – which highlights that the only advice he can offer, which is genuinely based on evidence is ‘use sunscreen’.

For my part, I would like to take a fresh look at how we make decisions in the NHS and the importance of something economists and psychologists refer to as action bias. Put simply, action bias is the idea that when faced with difficult situations we tend to get the feeling that we need to take some action regardless of whether this is a good idea or not. It follows that we would make better decisions if we had an awareness of the unconscious psychological processes that drives our decision making at times of stress.

I recently noticed a link to a great 7-minute video that focusses on what happens in a goalkeeper’s head when they try to save a penalty. Now this is all pretty close to home for me – as some of you may know my son started a career as a professional goalkeeper and has since managed to turn his passion for football into a career as a goalkeeper coach.

As my son always tells me, goalkeepers love penalties. They can’t lose. The striker is expected to score but if he saves a penalty he is a hero. Interestingly, when he was still playing in goal he took this a stage further and decided that he should do everything he could to distract the striker as he prepared to take the penalty. He would walk out of the goal and move the ball, argue with the referee and tell the striker where he was about to hit the ball. It was a nice theory, but it was at best unproven – the only certain thing was that he got booked a lot and created a name for himself with referees.

So what did the video have to say? Academics, with nothing better to do, spent a lot of time reviewing thousands of penalties and they found out something very interesting. They discovered that goalkeepers would save more penalties if they did nothing, or just stood still.  But, this isn’t what goalkeepers are trained to do and a heroic, if pointless gesture, feels much more satisfying than remaining rooted to the spot. This is where action bias comes in, we feel better doing something and there is plenty of evidence that doing less has better outcomes in other fields too. Traders on the floor of the stock market are primed to do things and make rapid decisions, but the research shows that those who trade less are actually more successful.

In healthcare, there are many examples of action bias. GPs opt to prescribe antibiotics even when they know it will have no impact and contributes to broader harm. And, politicians and policy makers exhort general practices to offer more appointments, doing more and working harder, when we know there is greater patient satisfaction in practices who offer fewer appointment slots. Or put another way, general practices that struggle most are those that respond to the increasing pressure they are under by doing more – offering more appointments rather than standing still for a bit and thinking.

So, I offer three reflections to the new leadership team.

First, the answers to problems are often counter intuitive. So, put simply, doing something – anything – especially when you have no evidence that it is the right thing to do, may not be smart. You may just be digging a deeper hole.

Second, productivity is not just about doing more – headline figures for productivity invariably rise at a time of austerity or financial crisis – but being genuinely productive, so improving how effective we are rather than just being more efficient, takes careful thought and reflection.

And finally, I would encourage everyone to spend more time following up random links and videos as they may just trigger a new way of looking at the same intractable problems. If we are serious about transforming general practice and primary care, rather than just doing more of the same, we need to give people the ‘headspace’ to come up with creative solutions.

Rick Stern

Outgoing Chief Executive, NHS Alliance

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Guest Sunday, 25 October 2020

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The Primary Care Foundation supports the development of best practice in primary and urgent care. We apply our work shaping national policy to support local change. We use information to create understanding, driving improvements in care, reducing unnecessary variation across organisations and between clinicians and developing practical tools for front-line staff in general practice and urgent care.