Immune to Feedback? What NHS Governance Can Learn From Medicine


3 min read

The views and opinions expressed in this article are those of the author.

Here is something interesting: there are normal people out there who can predict the future better than others, including subject-matter experts.

In fact, between 2011 and 2013, a group of these normal people took part in a US Intelligence-sponsored forecasting tournament, answering thousands of questions about event probabilities: from recessions and stock price movements to wars and election results. The result? They ended up thrashing their competitors, including US Intelligence professionals with access to classified information.

You can read more about these individuals, and what makes them so good at forecasting, in Philip Tetlock’s 2015 book Superforecasting. The Canadian political scientist believes most public predictions, including by ‘experts’, are ambiguous or inaccurate, and their authors never held to account. He’s on a mission to make forecasting more scientific, and he thinks there are lessons we can learn to improve the situation.

So what do his ‘superforecasters’ do differently?

Various things, but essentially it’s about how they think, not what they know or believe. They check their ideological inclinations, break big problems into small ones, and think probabilistically.

Crucially though, they also get, and use, feedback. Cold feedback that forecasts are clearly accurate, or clearly not.

Feedback, Tetlock reckons, is crucial to making forecasting more scientific. Without it, forecasters can’t be shown to be ‘wrong’, public debate can’t evolve, and we can’t learn from mistakes.

The value of feedback (and breaking habit) in medicine…

As with forecasting, Tetlock reminds us, so once with medicine.

In 1799 George Washington died, despite deathbed doses of mercury, induced vomiting, and forced bleeding. Despite these treatments? Because of them? By merely observing that one event, no one in 1799 could be certain. They hadn’t saved Washington. Maybe they had helped, but not enough. Maybe they had made his situation worse. There was no conclusive feedback. And so, in the absence of feedback, doctors carried on administering treatments like these as they had for centuries.

It was the launch of randomised controlled trials in the twentieth century, the subjection of treatments to experiment, and the monitoring of thousands of outcomes, that really brought feedback and science to modern healthcare. Trials could demonstrate what worked and what didn’t, and that feedback cast doubt on doctors’ traditional answers and helped propel medicine’s scientific advance.

Yet old habits die hard. Early clinical trials in the National Health Service were met with medical resistance. In the 1950s Arthur Cochrane, who faced constant objections from medical colleagues when running randomised clinical trials, concluded that the new NHS had ‘far too little interest in proving and promoting what was effective.’

Perhaps this scientific process — doubt, experiment, validate — made physicians, respected figures of authority, nervous. Perhaps too many had believed for too long that their judgement did not require further experimentation. Feedback via trials transformed modern medicine, but feedback is often uncomfortable and can meet resistance. Changing ‘the way we do things’ is rarely straightforward, even in ‘scientific’ professions.

From ambition to reality in NHS Governance

So, as feedback has improved medical practise the question must be asked: how can it be used to improve governance in healthcare? After all, is governance habit and convention or skill and practise? Can these lessons be applied in the NHS boardroom?

The good news is the ambition to improve is there. Today, many NHS bodies recognise that ‘better governance’ has to mean more than just ‘better people’ or ‘better tech’. NHS governance professionals are trying to answer more fundamental questions: How can my organisation get more value from the board? How can our board packs drive better decisions? Are we having the conversations we need to be having?

And we can’t fool ourselves that the feedback isn’t there. 70% of Board members think their Board packs and meetings do not give enough attention to long-term strategy. 60% believe papers are too backward-looking. 75% think their packs are too long. Board members allow three hours of preparation time for their meetings, yet most readers need nine hours to wade through packs averaging 300 pages. Two-thirds of a pack going unread before entering the shredder is a sad way to end a reporting process costing cash-strapped NHS Trusts an average of £2 million a year.

How can the ambition, and the feedback, break bad governance habits? Our challenge to governance teams within the NHS is: can you face the feedback? Can we free ourselves from habit — the usual agenda order, the data-drenched papers hiding crucial insight? Can we take time to consider ‘what works?’ and engage our Boards in ‘proving and promoting what’s effective’ in governance just as Cochrane did in medicine?

We know boards can, we see it every day. Let’s take that knowledge, and the feedback we have, and work to make our ambition the reality.

Roland is Client Relationship Manager at Board Intelligence. He holds a Bachelor of Arts degree in History from Cambridge University with a particular interest in modern American politics, has extensive work experience in SaaS and augmented reality, and is an avid 5-a-side player.

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