Transformation not Tampering David and Sarah Kerridge Dr W Edwards Deming started a revolution when he took his ideas on management, and those of Walter A Shewhart, to Japan. Because of Japanese success, a confusing variety of "Quality systems" are spreading in the West. Many are based on a faint echo of Deming's teaching, but his most powerful ideas are unknown or misunder- stood. The popular "TQM tools and techniques" focus on a very small part of the possible gains. Useful enough in their place, they can easily divert attention from the total transformation that is needed. Health is quality Transformation is hard to understand when you have never seen it. But in the medical field we can see similar ideas at work. Health is quality: the quality of life itself. Health has not yet been transformed, as it could be. Even so, enough has been done to show how some of the new ideas work, and why they are often neglected. There are two opposite approaches to health. One concent- rates on the sick, to comfort, and sometimes cure. The more subtle way deals with the whole population, most of whom are healthy. Take the problem of lung cancer: the obvious approach is to offer cough medicines and pain killers, or surgery. In the long run, an anti-smoking education campaign will do more good. This is likely to work best as part of an overall plan to promote positive health: for example by reducing tensions and pressures that make people want to smoke. In the same way, management may work at various levels. It may cope well with crises, or set up problem solving teams. Far better to think positively, and act before problems arise. This way is more effective and very much cheaper. So why is it neglected? Let us see why prevention has such low priority in health. Prevention is "theoretical" To ease suffering, we must know the immediate problem - pain, or choking, for example. We often need to know little more. To cure the illness, we need accurate diagnosis and effective treatment. To prevent an illness we must understand the whole complex system that leads to the disease. Then we can act effectively, without causing harm of some other kind. Of course, nurses and surgeons benefit from theory. Deep understanding makes every action safer and more effective, and leads to improvement. But care and treatment also depend on skills, which are highly visible and universally admired: pre- vention depends totally on theory. Hospital medicine also in- volves fascinating new technology, while prevention seems embarassingly simple, once we know how to do it. So we often find that the theory involved in treatment seems more concrete, and has more appeal, than the abstract theory of positive health. Prevention takes time The lung cancer patient may do better if he stops smoking, but most of the damage has been done. Prevention should start when the patient is healthy. This causes difficulty in two ways. Even when we know how to prevent an illness, we have to cope with the problems already caused. This often takes up so much time and energy that research and health education are neglected. With other diseases we may still be searching for the cause. Another problem is that, with long delays between preventive action and result, we can rarely wait for proof that a particular way of intervening will be best before we begin a large-scale preventive campaign. So theory, rather than direct experience, is again vital at the start, though we check as the programme proceeds. These obstacles to prevention might be overcome, if they were all. But problems of organisation and of human nature make progress very difficult indeed. Self interest is not enough We know how to prevent AIDS and lung cancer, but they are not prevented. To get rid of them, we must change the way we live. Cholera is difficult to prevent, but is prevented, because someone else can purify the whole water supply. It would be cheaper for each of us to purify our own drinking water. In an emergency, we would do it, but once back to normal, we would take chances. Even with our lives at stake, we are dominated by short- term thinking. Why else do we need laws to make drivers wear seat-belts? In the same way, the new management philosophy requires transformation of ideas and behaviour throughout the organis- ation. We can learn to think long-term, but not if the system is against it. Linked to the problem of motive is the whole structure of the health providing system. This is geared to the care of the sick, rather than the promotion of health. The rewards, in job satisfaction and the approval of others, even more than in money, are also biased against prevention. The nurse who cares for you when you are ill is a ministering angel. The surgeon who removes a cancer is a life-saving miracle worker. The person who tells you to stop smoking is an interfering busybody. Enthusiasm is dangerous Care for the sick, even without much knowledge, often does good because the state of mind of the patient is so important. Any treatment, if not actively harmful will often work if everyone believes in it. This is why, before scientific testing, each new treatment usually produced good results for a time. But then people lost faith in it, and it failed. This happened so often that "double-blind" testing is now the rule. When new drugs are compared, neither patient nor doctor must know which is being given. So if a difference is found it will be real and lasting. In contrast, enthusiasm alone can not prevent disease, if only because the time between action and result is too long. So prevention depends on rigorously tested scientific theory. It must work whether anyone believes in it or not. Prevention still works In spite of this, if we look at the history of medicine, prevention has done more to improve health than new treatments. Some improvement is due to a higher standard of living, but not all. Health has improved in very poor countries, wherever medical knowledge has been applied. Providing clean water, and killing mosquitoes, are less exciting than building hospitals, but they save more lives. One reason why prevention based on theory is so successful, is that there is a "bonus effect". When an illness is prevented by healthy living, other benefits often follow. Stop smoking, to prevent lung cancer, and the risks of heart disease, ulcers, and even impotence fall as well. The same actions which stop the spread of AIDS will stop the spread of other viruses, including one which causes jaundice. There are so many examples that we may take the "bonus effect" to be the usual rule. All this applies to management in general, not just the management of health. Transformation has not the immediate appeal of short-term "Quality initiatives". Often these are introduced with enthusiasm, flourish for a while, and then collapse. Const- ant change in pursuit of the latest initiative is simply tamper- ing with the system. Enthusiasm gets things started: but strictly tested theory makes things work. The "bonus effect" is less well known, but equally real. Change to a single supplier, for example, and benefits spread throughout the system. Some effects are predictable, but there are usually pleasant surprises. For example, when raw materials are less variable it becomes easier to see where a process is going wrong. The most important lesson is that in management, as in health, we too easily become wrapped up in coping with problems, or even solving problems, without stopping to wonder why the problems exist at all. Immediate pressures and management struc- tures strengthen the grip of short term thinking. The manager who is good in a crisis is successful in a highly visible way. The manager who transforms the system makes things easy for others, and makes the company many times more profitable. Everyone likes the results, but only those who really understand will give credit where it is due. Others will assume the results are due to luck, and may blame the manager for being too easy-going. Fitness means more than not being ill. We can be perfectly well, but quite unfit to run a race. In the same way, an organisation can run smoothly, but still go out of business. In a world of rapid change, survival depends on innovation. The computer we wondered at ten years ago is now a museum piece. A healthy organisation is bursting with confidence and new ideas. The first duty of management is to promote positive health in this sense. We should not think that a quality programme must start with improvement techniques, and move slowly towards pre- vention and innovation. It should start with education, directed towards complete transformation of the system. Improvement pro- jects may be used as part of the education process, but they must never distract from the real aim. The most important thing to establish is that there is a long term future. Without this, no- one will take transformation seriously. We acknowledge with gratitude the help of many friends in writing this article.