This is the third in our short series of blogs on ‘simple tools for improving healthcare’. Tool 1 – learning from the past - is available here; and Tool 2 – a clear theory of change is here.


Tool 3: The naïve question

I was recently in a session badged as an ‘Introduction to Population Health Management’. It was attended by leaders from across a local health and care economy and facilitated by two experts who took the group through various presentations and group exercises.

One of these exercises was to review – and rate using a Red / Amber / Green scale – progress towards ‘value-based contracting’. The group I was in dutifully discussed its way through the questions given to them.

After 15 minutes or so a consensus formed. The group was inclined towards an ‘Amber’ rating, given the lack of apparent examples of value-based contracting in their area.

But then one participant put a spanner in the works:

“Sorry if I'm being dim, but what is value-based contracting?”

Her question was enough to cause the group to fall silent. Several of the stronger Amber advocates looked down at the table.

If the incident had stopped there, it would have been instructive enough in that:

  • Without her question, the Amber rating would have prevailed; it would doubtless have been reported ‘up the chain’, spurring action to turn the situation ‘Green’; and
  • A senior group of local NHS leaders had just spent time rating their system against a concept and implied standard on which there was no (shared) understanding – either in terms of definition or expected benefits.

But it’s value as a teaching moment (for me) was then improved upon. One of the group asked for help in defining value-based contracting. Both facilitators came over – one after the other – to give different and partly contradictory definitions. Defying my expectation of further questions, the group then returned to the task and its Amber rating. Old habits die hard.

There are several lessons that could be taken from this short episode. One I'm afraid is about the top-down nature of the NHS: local leaders are accustomed to following instruction, however bad.

But the other – hopefully more fruitful – lesson is about the value of the naïve question.

Having the wherewithal and courage to seek clarity, rather than assuming it is present in the minds of everyone else, is a simple, powerful and cheap tool. Used more often, and taken more seriously, the naïve question could save plenty of time, resources and tail-chasing.