Baroness Dido Harding: Levers, leadership and light-shining

Source: NHE July/August 2018

NHS Improvement (NHSI) will focus on a collaborative approach when spending extra money in the future, revealed Baroness Dido Harding, the regulator’s chair. NHE’s Jack Donnelly reports.

Organisational team-ups, a shift in culture, and using the ‘people lever’ in NHS care across the country – these aims are amongst the plans for NHSI’s chair Baroness Harding, who outlined the long-term goals for the 1,300-strong organisation in London in June.

Speaking at ExCeL to delegates at the Health+Care Show, Baroness Harding opened proceedings discussing what is, in her opinion, the greatest tool for improving patient outcomes: a fully integrated health and social care service.

“If there is one answer worldwide people might think will be the solution for coping with demand for healthcare, it is integrated patient pathways – from patients’ homes all the way through the health and social care system,” she said. “It’s shaping hugely the way that NHSI, NHS England and the other parts of the national infrastructure work together. If the answer is to have integrated healthcare on the ground level, then we need to mirror that behaviour too.”

The chairwoman is referring to a recent “profound shift” in management between NHSI and NHS England. In May, the pair announced plans to work closer together, including by establishing a new NHS Executive Group headed by two new CEOs who will oversee all national and regional directors from the two national arms of the NHS.

“The NHS is the best healthcare system in the world. We don’t say that enough,” Baroness Harding noted. But those who disagree – particularly those in her own political party, as she also owns the Conservative whip for the House of Lords – point out that you only have to be a patient for 10 minutes to know that the service has lots of room for improvement. She accepted this: “It could be so much more efficient and deliver so much better outcomes for patients.”

When spending the recently-pledged £20bn year-on-year cash boost for the NHS by 2023, the NHSI boss believes her organisation needs to be more “efficient and effective” and focus on better patient outcomes. How, then, will Baroness Harding, just eight months into the role at NHSI, lead the organisation to introduce a cultural shift to    a workforce of 1.3 million – around 1,000 times the size of NHSI?

For her, the solution rests on seven key ‘levers’ to create organisational change, and therefore improve patient outcomes.

Seven levers

The first rests on fiscal levers: Baroness Harding claims a change in the way financial incentives work is a prime factor in improving national quality of care. “We know they need to change the way financial incentives work, especially to encourage system working,” she said.

“Whatever we create, there will be consequences, but we get to set the rules of the game to drive the behaviours and the collaborations that we want.”

Another key approach is a change in management: increased focus on performance-based management and the holding of staff members and leaders to account can have “huge consequences on the way people behave,” Baroness Harding argued.

Building on that, the next two improvement levers focus on “shining a light” on best practice, from the frontline to the backend of the health service. NHSI identified areas where operations and administration could be improved at a regional or national level – procurement, pathology and estates, for example, were areas to which the regulator “could really bring some help.”

On the frontline, Baroness Harding promoted the work of the Getting It Right First Time (GIRFT) scheme. Focused on reducing variations and inefficiencies in patient care, GIRFT has already led to a reduction in litigation claims against the NHS, seeing almost one in 10 fewer claims in 2016-17 than the year prior. “We need to take practice like this and put it at the heart of what we do,” she explained.

The fifth mechanism – dubbed the ‘people lever’ – is believed to be the most effective and powerful tool for a cultural  shift  in  the NHS, according to Baroness Harding: “NHSI makes direct decisions of chairs of trusts, and we have huge influence over chair appointments of foundation trusts and of executive appointments. There’s probably not an executive board in the country that doesn’t have an NHSI person on it.

“We could play a really meaningful role in shifting the culture of the organisation if we role model and think about what best-practice people management and leadership really is. I think this could be easily the most powerful way to drive a change in culture and deliver the outcomes that we all want.”

With NHSI and NHS England looking to collaborate in the near future, perhaps Baroness Harding believes appointing those who ‘buy in’ to the integrated, system-wide approach is the key for driving improved patient outcomes.

System working on a national scale between NHSI and NHS England – and, on ground level, utilising sustainability and transformation partnerships to reduce the numbers using acute services and thus contributing to the issue of ‘bed-blocking’ that has plagued the nation’s wards for years – is Baroness Harding’s sixth key lever.

“On a bad day, NHS England and NHSI give completely contradictory instructions and encourage commissioners and providers to have a jolly good fight,” she revealed.

“That is not the answer to solving the integrated patient pathway problem. We need to change, and we need to change significantly, to reflect what we’re asking staff out in the country to do. We need to move from a fragmented approach to a much more coordinated one, which will make some massive changes in our organisational system.”

With a continued focus on the long-term destination in mind, added Harding, relentless pursuit of integrated working will lead to engaged staff – resulting, ultimately, in good practice.

The seventh and final progress lever rests on the value of data and the digital innovations that will improve the overall experience of  a patient. By once again shining a light on best practice, this time of the digital world – such as allowing patients to take ownership of their own data and encouraging medical clinicians to realise the importance of data – Baroness Harding claims digital transformation will deliver the best outcomes for patients.

But while ambitious, Baroness Harding noted that none of the levers involve “telling staff members what to do.” The NHSI chair has crystal-clear intentions for collaboration, both between the national sector of the NHS and between the trusts up and down the country.

It certainly won’t be smooth sailing, however. “It is only early days, and we will go through rocky periods as we change and develop,” she said in her concluding remarks. “But the best thing we can do is encourage more coordination and more improvement, and less regulation and less fragmentation.

“We don’t have the best outcomes, and we still need more money – but if we went out onto the streets anywhere in the UK, I know that if we spoke to half a dozen people they would all say that the NHS is one of the things that makes them incredibly proud to be British.”

It seems that, on the month of the health service’s 70th birthday, levers are the key to fulfilling that pride.


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