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Planning to succeed: NHS boards need to focus on long-term strategy

Guest blog by Suzie Bailey, development director and acting operational improvement director at Monitor, who says NHS boards need to focus more on long-term strategy.

“If you fail to plan, you are planning to fail” is the famous quote attributed to Benjamin Franklin. I heard it quoted many times by senior managers when I was a general manager, but how much time and effort do we put into planning in the NHS? Do we equip our staff, particularly clinicians, to plan effectively?

Many would argue that the current tough financial environment for the healthcare sector makes this question irrelevant. They believe that the scale and scope of financial and structural health economy issues affecting institutions is such that doing strategic planning – or the quality of it – doesn’t really matter.

However, evidence from the public and private sector shows that having a good strategy is always critical to the delivery of an organisation’s overall vision for service users or customers. Chiefly, because a good strategy sets out the choices and principles needed to help an organisation achieve its long-term objectives and will take account of the environment they’re operating within.

Research also demonstrates that boards spend too little time, energy and thinking on strategy. For example, Harvard Business Review observed that “most boards aren’t delivering on their core mission: providing strong oversight and strategic support for management’s efforts to create long-term value”.

What does this mean for boards at healthcare providers? If senior leaders aren’t spending enough time developing and adapting local strategy, are they missing an opportunity to counter some of the financial and operational pressures they face?

At Monitor, we want to support NHS foundation trusts to focus more on strategic planning as a way to improve their financial and operational sustainability. In particular, good strategy development can provide valuable assistance to identifying and prioritising the strategic choices necessary for safe, effective and person-centred patient care. However, we see when reviewing foundation trust annual plans that many do not address issues beyond the immediate term.

Strategy and its development is also becoming an important feature of the health sector’s regulatory environment. For example, it is a prominent part of the ‘well-led framework’ used by Monitor to assess NHS trusts for foundation trust status and, for the last couple of years, the framework has been used by foundation trusts as a structure for their governance reviews.

But while extremely useful, strategy development can appear daunting. Chairs and chief executives often tell us they need help to develop the capability to do strategy development and to do it well.

Responding to this, Monitor has co-developed a range of resources to help foundation trusts with strategic development. One such resource is a strategic planning toolkit. Co-designed and piloted with foundation trusts, the toolkit guides them through strategic planning in seven steps. It enables them to test the robustness of their plans and whether they need to ‘re-create, refresh or re-commit’ them. The toolkit’s framework is being more explicitly incorporated into our regulatory approach to make sure the sector gives sufficient attention to sustainability of services – which is what Monitor is tasked in law with ensuring.

But in addition to a good strategy, what else is critical if boards and leaders of healthcare organisations are to maximise the chances of their strategies succeeding?

Peter Drucker is credited with saying: “Culture eats strategy for breakfast”. And indeed, the excellent mixed-methods research from Mary Dixon-Woods and colleagues on culture and behaviour in the English NHS highlights the importance of clear, challenging goals for high-quality care and the need to nurture caring cultures. They identified the requirement for “a clearly articulated vision, including explicit goals for quality and safety and a strategy for achieving them” and described the “frequent misalignments between the ways the blunt end and the sharp end of organisations conceived of quality and safety problems and their solutions”.

From our work with providers, we recognise how critical leadership culture is to enabling an organisation’s staff to provide excellent patient care for patients, including through service redesign and progressing new care models. Again, providers tell us they would like ‘help with the how’ on developing culture.

Together with the NHS Trust Development Authority and Care Quality Commission, we are meeting this request by launching a new programme focusing on culture and leadership.

We think it is essential to work on strategy and culture together. This requires an explicit organisational leadership strategy. We look forward to learning with providers over the coming months, to help ensure the NHS is successful long into the future, and well beyond the Five Year Forward View.