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Helen Bevan on Patterns and Antipatterns

The Trust Board is facing significant performance challenges. This might be a financial shortfall, a potential breach of a key quality standard or staffing difficulties. What approach should the Board take? There are two obvious answers. The first is to do more of, or less of, what it is doing already. So, for instance, in the case of financial difficulties, to ask every department or service to take a percentage budget cut across the board. There are short term benefits to this approach but it is unlikely to create the radical, sustainable change we need for the longer term. A second approach is to apply creative thinking to the difficult situation and come up with innovative situations. This approach is likely to produce better ways of tackling the chronic problems that create poor performance but it still has its shortcomings. The benefits and consequences of truly innovative solutions are unknown. They might work and they might not. The potential risk is high.

There is a third approach. That is to identify potential “patterns”. Patterns are principles for change that have been used before, often in a different context. In our development work in the Modernisation Agency, we have identified 20 initial patterns for healthcare improvement. They are time-proven solutions to commonly occurring problems. An example is the “80/20 rule” which can be applied to almost any healthcare context. This asserts that around 80 per cent of the effects generated by any large system are cause by 20 per cent of the factors in that system. To put it another way, the majority of results derive from a minority of causes. If we focus our performance improvement efforts on the small number of factors that make the biggest difference, we are much more likely to achieve our aspirations. Most of us are aware of this pattern, yet how many of us apply it systematically in our strategies or daily work? In the next phase of healthcare improvement in the NHS, we need more rigorous processes to identify our patterns; to codify and reuse the learning from the most successful change processes to get better, quicker outcomes across the whole system.

The concept of pattern originated in software engineering. It represents an attempt to distil experience, which, through its assimilation, conveys expert insight to inexpert developers. The “pattern” approach has spread to many other industries and development disciplines.

The most recent advance in this approach has been the identification of “antipatterns” as well as patterns. It is estimated that, across all industries, up to 75 per cent of improvement projects fail to achieve their objectives. Sometimes, the act of attempting to apply a “best practice” solution leaves us worse off than before we started. Antipatterns are patterns that tell you how to go from a problem to a bad solution. If a pattern represents a best practice, then an antipattern represents a lesson learned. Antipatterns arise from repeated failure of corporate change initiatives. They are an attempt to understand, prevent and recover from them. Antipatterns are valuable because it is often just as important to see and understand bad solutions as it is to see and understand good ones.

In order to deliver our radical NHS improvement agenda, we probably need to put just as much effort into identifying and avoiding antipatterns as we do into distilling and applying patterns. Within the NHS, many of yesterday’s approaches to change have become today’s antipatterns. The long list includes business process reengineering, best practice databases, nationally driven change programmes. It is likely that many of today’s hot solutions will become the antipatterns of tomorrow.

We’ve been testing the concepts of pattern and antipattern with healthcare teams. The work is demonstrating potential. However, we’ve found a tendency to dwell on the antipattern (what we’ve learnt hasn’t worked) rather than the pattern (what might work). We need to use antipatterns to move quickly through the negative issues and on to positive solutions. Some teams make repeated (almost obsessive) use of a very small range of patterns. The focus on patterns more generally can encourage us to utilise a wider range of solutions and get better outcomes for our patients.

So, to return to our hypothetical Trust Board. Identifying and applying patterns can help us to choose approaches to change where the benefits exceed the consequences. An explicit focus on antipatterns can help us avoid strategies where the consequences are likely to exceed the benefits. Patterns and antipatterns have the potential to become important concepts in healthcare performance improvement. They can provide us with laws, guidelines, knowledge of human biases and design considerations. They can help us to distil existing knowledge to increase the probability of a more successful future.


Brown W, Malveau R, McCormack H, Mowbray T, (2003) Antipatterns, John Wiley and Sons.

Lidwell W, Holden K, Butler J, (2003) Universal Principles of Design: 100 Ways to Enhance Usability, Influence Perception, Increase Appeal, Make Better Design Decisions, Rockport.

Helen Bevan is Director of Service Transformation at the NHS Institute for Innovation and Improvement.

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