The Cost of Saying Yes: When Good Initiatives Overwhelm the System
by David Nicholson
An organisation can approve a series of entirely sensible initiatives and end up with a strategy it cannot deliver. Let’s think about a health service introducing an electronic patient record, redesigning outpatient care, improving productivity, and developing new workforce models. Each programme of work has a rationale, a sponsor, and an account of the benefits it will deliver, and each may have secured funding. But, if we look through the lens of the organisation that needs to deliver those plans, a different point of view emerges.
Several business cases for change may depend on the same capacity that has already been promised somewhere else. The same clinical leaders have to help design the pathways, the same operational managers have to release staff, maintain services, and implement new working arrangements, and the same data specialists have to establish the evidence. The budgets are separate, but the organisation receiving the change is the same.
Vsevolod Shabad’s paper, The architecture of focus: how governments resist initiative overload, describes “strategic subtraction”, making deliberate choices about the volume of concurrent initiatives before overload forces those choices upon us. It is a useful contribution because it treats focus as something institutions must design into their decisions, rather than something that can be left to individual teams to manage once those decisions have been made.
For those of us working in systems transformation, it opens a further question about how we change the system so that its ambitions, its commitments, and its ability to act remain connected. That means looking beyond whether individual programmes are affordable or well governed, and asking whether the organisation as a whole has the capacity to deliver what it has collectively promised.
The capacity we promise more than once
A business case can be affordable within its own budget while depending on an unrealistic contribution from the wider organisation. “Clinical engagement”, “operational input”, and “business readiness” can sound like modest supporting activities when they appear in a plan, but in practice they involve consequential work, including resolving disagreement about pathways, defining requirements, testing unfamiliar processes, changing rosters, and supporting colleagues through adoption.
Additional programme staff can help with that work, but they cannot fully substitute for the judgement and authority of the people who own the service. That makes organisational capacity more specific than a headcount, or a general statement that teams are busy. We need to understand which decisions and tasks depend on which people, when their contribution is required, and what else they are responsible for at the same time.
Timing matters as much as total effort. Two programmes might be entirely manageable over the same three-year period but become unworkable if both require the same teams to redesign services, test systems, and train staff in the same quarter. Looking at each programme separately will not necessarily expose that problem because, within the boundaries of each business case, the assumptions may be perfectly reasonable.
The benefits can overlap too. A digital programme and a productivity programme may each assume they will release time from the same administrative tasks. Unless those assumptions are reconciled, the organisation can promise the same improvement twice while understating the effort required to achieve it once. These are not simply programme management issues to resolve after approval. They are matters of system design, and they belong in the decision to proceed.
The cost of working both ways
There is an easy administrative response to overload, which is to combine several initiatives beneath a single transformation programme. Sometimes that is useful because shared leadership, coordinated dependencies, and a common operating model can remove duplication, but a new title does not, by itself, change what anyone has to do.
If the workshops, reporting requirements, implementation dates, and demands on frontline teams remain intact, the organisation has simplified the presentation of its transformation while leaving the workload largely untouched. A meaningful review therefore has to reach below programme names and examine the decisions, processes, controls, and behaviours those programmes create.
A new operational dashboard is introduced, but teams must continue producing the spreadsheets and weekly returns it was intended to replace. The technology has added a capability, but the work has accumulated. There may be perfectly good reasons for a period of parallel operation, but we should know what evidence will allow the older process to end, who has the authority to make that decision, and who is responsible for making it happen.
Ending the project without resolving those questions leaves the organisation carrying the cost of both ways of working. The same applies to governance. Creating a new forum can help resolve decisions across organisational boundaries, but if it has no clear authority, or simply repeats discussions already happening elsewhere, it becomes another demand on the people whose time it was intended to protect.
Digital changes what capacity can mean
At Tektology, we know that understanding what technology makes possible can change the work required, the information people need, and the choices available to them. Capacity is not simply something we have more or less of. It is something we can redesign, which is why digital belongs in the initial thinking about a system rather than being introduced once the operating model has already been determined.
An organisation may be planning to recruit more people to assemble information that could instead be captured once and reused. Several teams may be developing separate tools for problems that share a common requirement, while a process may involve repeated checks because nobody trusts the information being passed between organisations. Each situation calls for judgement about the underlying work before deciding what intervention is needed.
Automation may help, but so could clearer ownership, a shared capability, a different workflow, or removing a requirement that no longer serves a useful purpose. The value lies in understanding which combination will improve the system rather than assuming that adding technology will, in itself, create capacity.
AI brings this issue into sharper focus. A tool that produces a report in minutes may save considerable effort in drafting, but if it also creates more material for senior people to review, reconcile, and approve, part of the workload has moved rather than disappeared. We need to examine the whole process if we want to understand whether capacity has genuinely been released.
There is also a period when changing the work consumes more capacity before it releases any. Data needs attention, people need time to learn, and new arrangements need to be tested and improved. A credible transformation plan has to resource that transition because future productivity cannot be treated as though it is already available to fund the work needed to create it.
Choosing what continues requires judgement
A simple rule that every new initiative must displace an existing one can expose a conversation that has been avoided, but it cannot settle the decision. Programmes differ in their demands, dependencies, and consequences, and stopping a foundational investment might make several other commitments less deliverable, while closing a small experiment could remove a valuable opportunity to learn. Necessary transition work may also need to run alongside the service it will eventually replace.
The task is to understand what the whole portfolio is trying to achieve, and which sequence gives it a credible chance of doing so. Some activity should stop because its purpose has disappeared or the evidence no longer supports it, some should be combined because it addresses the same underlying problem, and some should wait until a dependency or capability is ready. Other work needs protection precisely because it is essential but less visible.
Those choices require authority at the level where the competing commitments originate. A local team cannot resolve overload created by several national programmes simply by coordinating better, nor can a programme manager quietly abandon an obligation owned by someone else. The people setting priorities need a clear account of their combined consequences, and a route for making the necessary trade-offs.
In public services, this includes an honest conversation between political ambition and operational reality. Elected leaders are entitled to set direction, while the role of those advising them is to make the delivery consequences visible, including what a new commitment will delay, displace, or require. Leaving those consequences unresolved does not remove the trade-off. It transfers the decision to people with less authority and fewer options.
Assurance should test the burden of change
This has implications for what we assure. Alongside progress within individual programmes, we should examine their combined demands on the organisation, including whether the necessary people are available at the points when decisions must be made, whether dependencies are actually being resolved, whether the expected reduction in work has occurred, and whether benefits remain credible when they are considered together.
We should also look at whether the organisation has enough room to learn and respond. Time for testing, resolving problems, and improving the new service needs to be built into delivery because, if every available hour is already committed, an unexpected issue immediately competes with another promise. A system with no spare capacity has very little room to absorb the realities of transformation.
Successful implementation should therefore include evidence that the organisation can sustain the new way of working. That may mean retiring an old process, ending duplicate reporting, withdrawing a temporary arrangement, or transferring a capability into routine operation with clear ownership. The meaningful test is not simply whether the programme has completed its activities, but what has actually changed for the people doing the work and for those receiving the service.
At Tektology, this connects strategy, transformation, and assurance. We need to understand the problem before committing to an intervention, consider how technology changes the available answers, and keep testing whether the resulting system can deliver what was intended. Independent advice must also include the willingness to recommend that worthwhile work waits, that an existing commitment changes, or that a proposed programme is unnecessary, because the quality of that judgement matters more than the volume of activity it generates.
Every approval makes a claim on the organisation’s future capacity, which means saying yes to one thing can change what it is realistically able to do elsewhere. Leadership means understanding that claim, making the trade-offs visible, and taking responsibility for what those choices leave the system able to deliver.
David Nicholson is Global CEO of Tektology, a systems transformation advisory working across the UK, Australia, India, Canada, and beyond. He brings more than 20 years of senior public sector and health system leadership across several jurisdictions, including running operational health services, corporate functions, and complex reform programmes, and holding Deputy Secretary roles in government. David currently chairs the Independent Digital Group for England’s New Hospital Programme and serves on its Independent Technical Review Panel. He is a former IPAA State President and National Board Member, an ANZSOG EMPA valedictorian, and a recipient of the IPAA National Young Public Sector Leader Award.