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Keeping NHS services healthy during enormous change

Richard Jones, health director at transformation consultancy Moorhouse, discusses the balance between day-to-day delivery in the NHS and wider strategic change.

While the transition to a new system formally concluded on 1 April 2013, the NHS remains in the midst of the biggest reorganisation in its history with the political and public pressure for success immense. Complexity has been amplified by the fact that the transition has been externally ‘dictated’ by government policy, and within a context of increasing financial pressure – rather than generated from within the health sector itself. Consequently, the journey from the previous state to the new state has been extremely challenging with, at times, insufficient understanding of what the new world should look and feel like and, importantly, why the system should move there.

In many ways, the fact that the change has been designed externally and introduced as an external ‘shock’ to the system is of little consequence to healthcare providers; their priority is, and must remain, the patient. The questions about how these services are commissioned, and in whose name, are secondary to the need to safely deliver high quality care today. However, meeting these day-to-day delivery challenges within a changing system, in which service demands and decision-making authorities are shifting, is difficult.

If transformation in the NHS is to be successful, a balance between day-to-day delivery and strategic change needs to be struck. Furthermore this needs to be implemented in three different – but inextricably linked – ways:

1. At a system-level, to ensure the whole works together and leads to a set of collective ambitions;

2. At an organisational level, to ensure roles and responsibilities are clearly defined and understood; and,

3. At a team / individual level, to ensure key individuals understand the context, and are not overburdened by excessive demands outside their core responsibilities or stretched in too many directions.

At the system-level performance issues are increasingly related to challenges generated and faced elsewhere. For example, pressure on A&E departments can of course be symptomatic of inefficiencies within the department itself, or issues with transferring patients between different departments within the same hospital. However, more often it will be a consequence of inadequate demand management linked to access to primary care; or of inadequate social care provision preventing early discharge. As A&E departments are often the most visible link in a chain, issues with their performance can therefore be a barometer for inefficiencies across a whole health system.

Managing these spill-overs requires a more integrated view of care, thinking about the patient and the ways they behave and interact with the system, rather than just concentrating on one area of care. After all, if people are unable to get appointments with their GPs, they will end up visiting A&E – and channelling more money and resources to A&E departments is not going to fix the underlying problem. To achieve this integration, organisations need to work collectively and transparently, bringing together multi-disciplinary teams involved across each care pathway.

Multi-organisation collective working is a key success factor for a commissioner landscape and system leadership that is newly fragmented. From a transformation perspective, the question of out-of-hospital provision and alternative care settings must be addressed to enable A&E departments, and acute providers as a whole, to improve performance.

At the organisational level, the challenge is in managing incremental performance improvements alongside more fundamental, transformational changes. Success here will depend on the ability to set clear priorities and align the organisation behind them. This requires clarity from senior leaders about how their organisation can contribute to both transformational changes in the system and address immediate performance pressures. The ability to then translate this into a compelling narrative – and demonstrate visible commitment – is crucial, as is ensuring an appropriate and ruthless allocation of resource to only those initiatives that will deliver the strategic goals. Without this, organisations will find themselves pulled in too many directions, spread thinly, and ultimately working hard to achieve neither their transformational objectives nor their immediate performance priorities, whether these are targets around quality, safety or financial performance.

At the team and individual level, the challenge is that the same core team of frontline staff and clinicians will be needed to both shape the future changes and continue to manage and deliver day-to-day performance. Managing this tension requires clarity about what is important and why, but also empowerment of those critical individuals to enable them to delegate where needed and to genuinely shape their involvement to meet competing demands. The biggest enabler here will be motivated individuals and teams who understand the context in which their organisation operates, and have clear line of sight between their personal objectives and the collective strategic goals.

While the scale of change still needed could be daunting, the NHS has already taken huge steps to improve service and efficiency for both the patients and staff. By having clear plans at all three levels – system, organisational and team / individual – the change can be embedded more effectively for all involved.