Decision Making Blog #1: Better decision making: a neglected route to improvement?

There are two main routes for health and care services to improve the health of the populations they serve. They can: 

1. Decide what to do.  
2. Do it well. 

Obviously, both are needed. But do services make the most of both routes? Or do they pursue one and neglect the other? And if they do, where is the room for improvement?  

I would say that Route 2 (improving what is done) gets a great deal of time and attention, while Route 1 (deciding what to do) is neglected. This is a tricky claim to substantiate, but a quick look provides some evidence.  

Service improvement is not a specialism of mine. Yet, even as a very distant spectator, I can cite multiple methods and approaches that services use to get better at what they do. Lean. Six Sigma. Agile. PDSA cycles. QI. LGA Toolkits and support, Design Thinking, Skills for Care Guides, NICE Guides, service improvement and redesign (QSIR) tools. Services can use tools, such as Right Care, to see where to improve, before consulting large-scale programmes, such as Getting It Right First Time (GIRFT), to get it done.  

Even this casual glance reveals a wealth of tools, techniques, organisations and programmes dedicated to helping services improve what they do.  

So what are the equivalents for deciding what to do? Where are the programmes, guides, checklists, training courses (etc) for decision making? If you wanted to improve the quality of decision making in your organisation, where would you go?  

The lack of an immediate or obvious answer suggests something. And further research turns up little. Hence my claim: we don’t invest enough time, attention and effort into deciding what to do. Decision making is undervalued*.  

So how are strategic decisions made in health and care services? And how do we assess the quality of these decisions? Would we know good quality decision making if we saw it? Is there shared understanding of this? What about individual skills and attributes: do we know what makes a good decision maker? 

These questions spurred the Strategy Unit, as part of our work to develop the Midlands Decision Support Network, to design an education and training offer focused on decision making.  

For example, our ‘Decision Quality for Leaders’ programme will shortly complete its first run. We gathered and structured the best approaches, frameworks and tools we could find, before guiding a senior group through their use. It has been well received. And we have left participants with a clear sense of what better quality decision making looks like – and how to achieve it.  

Our work on decision making will continue to develop. We are preparing the leaders programme for future cohorts; we have added decision making sessions into our ‘Leadership for Analysts’ course; and we have developed a specific training workshop on ‘Thinking Tools’. More is needed and more is planned.  

This is not in any way, or even for a minute, to say that time spent improving service delivery is time wasted. It isn’t. But it is to say that we pay strangely little attention to the practice of decision making. It determines so much, yet we focus on it so little. Our efforts are a small step towards correcting this.  

* Here it is important not to confuse a ‘how’ with a ‘who’. I don’t doubt that the question of ‘who decides’ can generally be answered. An organisation, a committee, an individual: governance arrangements are usually well-focused on this type of question. The gap I see is in the how of decision making: the disciplines and methods that these decision makers use.