Last Word


A plan for the NHS that must be transformational

Source: National Health Executive Nov/Dec 2014

Steve Fairman, managing director at NHS Improving Quality, sets out his view on Simon Stevens’ important Five-Year Forward View document.

Five-Year Forward View, the new vision for the NHS in England, is a breath of fresh air compared to many of the strategy documents we have seen over the years. It is clear, to the point and sets out an unarguable case for change.

It presents powerful reasons why, in order to square the circle, change can no longer be simply a matter of incremental improvements within organisations – it will also need to involve transformational change across organisations and even sectors.

It is refreshing that the difficulties the NHS currently faces are fully acknowledged. This has to be our starting point. Sometimes strategies can seem remote – this one describes a reality that all those working in the health service will recognise.

Another significant positive is that this is change we are in charge of. This five-year vision has not been produced by politicians but by the service itself. It is also hugely encouraging that so many different organisations have already put their weight behind it.

At NHS Improving Quality, we welcome Simon Stevens’ proposals and believe that with our substantial experience in transformational change and improvement we are well-placed to support this call to action. We also welcome the planned review of our role over the coming months, which should ensure the work of the organisation is fully aligned with the objectives of the Forward View.

This document places great emphasis on working across traditional health and social care boundaries as well as new ways of working. I believe NHS Improving Quality has a vital role to play here because we have built up a store of transformational change knowledge and capability that simply doesn’t exist elsewhere in the system.

We also have a clear methodology based around the NHS Change Model and the ability to bring disparate organisations and diverse views to a single, shared purpose, which will be critical in taking forward the change agenda. 

To give just one example, as part of the prime minister’s Challenge Fund, we have been supporting 20 general practice collaborations with a combined seven million registered patients to explore new ways of working and improve patients’ access to their practice. The rapid learning from these pilots is now being shared across the country.

This is not to under-estimate the scale of the challenge we all face. People will need to rise above their own local and organisational issues and work together at a different level of collaboration than before. There will also have to be a significant shift in mindset both in the way we evaluate, and adopt, best practice and how we use data and measurement to assure progress.

If one was to level a criticism at this document it would be that the emphasis appears to be on a hierarchical model of change, relying mainly on extrinsic levers to bring about changes of behaviour, with less emphasis on intrinsic motivation, which is going to be absolutely key.

To bring about transformation on this scale, it is not going to be enough to pull levers from above and expect change to follow automatically. We will need to excite and enthuse health and social care staff about the new possibilities if we are to have a chance of making these changes a reality. They, together with patients and the wider public, should want to make these changes – not feel it is something they have to do. If we can achieve this internal transformation then almost anything is possible.

The section on public health, for instance, appears to place a high store on financial incentives to change activities such as diet and exercise. However, most evidence indicates their effects can be limited unless they work alongside a ‘motivational’ campaign to create a personal reason to change behaviours for each individual. 

It may also be optimistic to believe these public health interventions could save the amounts suggested over such a short time period. The recommendations in the last decade of the two Wanless reviews contained a similar focus on public health interventions, but had significantly less impact than anticipated at the time. It is important we learn the lessons as to why that happened. 

While the Forward View is strong in outlining the scale of the problem, what change in the NHS should look like and why it is necessary, it is, perhaps inevitably, much sketchier on how this will be achieved.

In many ways this is to be welcomed because local areas around the country need to lead implementation and play a significant part in designing their own sustainable future.  However, organisations on the ground may require support after reading this to help work through where they go from here and to build the effective local partnerships that will make change happen. We believe NHS Improving Quality has a vital role to play in supporting that.

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