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A changing mindset for a changing NHS

Richard Jones, partner at transformation consultancy Moorhouse, discusses new ways of working in the NHS.

These are fascinating times in the health sector. At a macro-political level there appears to be a broad consensus that traditional ways of working cannot continue, and that transformational change is required for the NHS to tackle the multiple challenges it faces: an ageing population with increasingly complex health needs; rising costs; financial constraints; and growing patient expectation. The answer is not more money – whilst a political funding race to meet the £8bn requirement may appease voters, it cannot be the answer to the challenges faced. In fact, chief executive of NHS England, Simon Stevens, said at a Reform conference in March 2015: “Anyone who believes we can spend our way to success needs to get their reading glasses on.” 

A mindset based on opportunity, not responding to directives 

Rather, the key is encouraging the NHS to embark on a journey that embraces an increasing sense of freedom and innovation – and, dare I say, entrepreneurialism. Those who work in the NHS have coped with huge change over recent years, both structural and financial. Now that the systemic overhauls are in the past (we hope), leaders can look towards what the new NHS landscape means for them and for their patients. However, following years of prescribed, mandated ways of working, adopting a mindset that seeks opportunity – rather than responding to directives – is far from straightforward. 

Changes in mindset cannot be achieved with a sledgehammer; new ways of working take time. An additional complication is that the NHS, both at organisational and system levels, faces a clear tension between the dual focus of delivering performance and of executing strategic transformation. Clearly, high levels of performance must be maintained before an organisation can earn the right to look at strategic development. Under-performance understandably distracts and consumes huge levels of organisational energy and attention; it is right that when there are major problems with patient care and safety, this becomes the focus. However, it must also be recognised that performance challenges are a constant feature and that time should also be carved out to explore strategic possibilities. For mindsets to change and new ways of working to occur, there needs to be the space for this to happen. 

The freedom now allowed 

After many reorganisations and system restructures, there is understandably little desire – or, in fact, need – for further structural change. Rather, the focus is on working with the freedom the system now allows to achieve better patient outcomes. There is an increasing appetite across the NHS to put in place the conditions that will incentivise and encourage innovative leaders to embrace the opportunity to do things differently. Ultimately, the responsibility for transformational change has to be with those individuals and teams that understand their population needs best. 

The journey to this new system has been a long one but the circumstances are now in place for leaders to work innovatively. As touched on earlier, there is political acceptance at a macro-level that the NHS must do things differently, but there have also been structural, cultural and funding changes too, which each afford opportunities to leaders in the sector. 

The many critics of the restructure triggered by the Health and Social Care Act 2012 will point at the resultant fragmented system that makes the execution of change more difficult. However, this assumes that change can only be driven top-down and that central policy-makers know best. There have been numerous top-down changes in the NHS, some of them successful but some not so successful. The objective of the Act was to place decision-making in the hands of those who are closest to the patient so they can commission services in the most effective way. In addition, with CCGs being smaller organisations, the opportunity to collaborate and work flexibly with a range of other organisations can enable an increasingly tailored and nuanced approach to delivering local health and care services. 

New approaches for achieving quality 

While the Act was a structural enabler, there have also been cultural and strategic nudges which have pointed at a direction of travel – rather than prescribing a solution. The Dalton Review in 2014 challenges the traditional model of acute hospitals and questions whether foundation trusts are the answer to delivering high-quality care. With some high-profile under-performing foundation trusts, the Review hints at other approaches for achieving quality. And – in a tone that is counter-cultural for the NHS – there are no specific recommendations, but rather an encouragement for leaders to innovatively consider what would work best in their organisation, and not to be constrained by traditional thinking. Similarly, the Five Year Forward View gives permission for a range of approaches to be explored and leaves it open for leaders of health and care organisations to determine what the best options might be for their local populations. With the Vanguard initiative underway, it will be interesting to see how these progress and how successful examples can be disseminated. 

This is truly encouraging, as trying new things requires a greater acceptance that some of those initiatives may fail. An understanding and acceptance of greater risk must therefore be tolerated. Clearly, in the NHS there are many types of risk and no-one would encourage taking risks with quality of care or the health of patients. However, by embracing risk there is the upside that innovation can accelerate and new models of care can emerge more quickly.

Across organisations 

The final part of creating the conditions for the NHS to transform has been the creation of initiatives that enable the funding of cross-organisation initiatives. These changes have taken many forms but all are aimed at increasing innovation. As this magazine covered in its last issue, Greater Manchester is one area that has fully embraced – and taken to a new level – the opportunity to pool funding. Its radical and fully devolved approach to health intends to create a far more holistic and integrated provision of health and social care. This devolution is ambitious and, while many of the details are yet to be determined, it is encouraging to see the ambition to embrace the opportunity for identifying new approaches to health challenges. 

As mentioned earlier, the Vanguard initiative is another example of identifying new approaches to healthcare. Twenty-nine sites have been selected to become sites for the New Care Models Programme, representing an important step towards realising the ambitions set out in the Five Year Forward View. These sites will share £200m – with a focus on integration and better patient care delivery in a variety of forms. The Vanguard sites chosen were already amongst the higher performing providers, which speaks volumes for the new tone being adopted in the NHS. While previous efforts focused on penalising under-performers, the new approach is focused on encouraging groundbreaking leaders to demonstrate what is now possible in this new system through greater collaboration and integration. 

The Better Care Fund and holistic approaches 

The Better Care Fund is another significant initiative that encourages transformation via the integration of health and social care. By creating a single pooled budget to incentivise the NHS and local government to work more closely together, increasingly holistic approaches can be developed that will improve patient care and relieve pressure on the creaking acute hospitals. 

As in any situation where there is change, there are those who quickly embrace new ways of working, those who hang back to observe developments before becoming involved, and those who are resistant to any form of change. With the conditions that encourage bold leaders to explore new ways of working, it is important that they can create the space for themselves and their organisations to do so. This is of course no easy task with the huge number of different priorities that are constantly competing for attention. But by taking time to focus on strategic development, leaders and their teams will find many of the solutions required to ensure the NHS can continue to provide the care we need. 

Change in any organisation is led from the top, so it is extremely important that senior leaders across the NHS can be the champions for seeking the answers to the complex challenges faced. As outlined earlier, there are many excellent examples of how the conditions are being created via national initiatives, and locally sought solutions. With more leaders like this, the NHS can begin to embark on genuine transformational change that places patient and public needs at its heart.

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