NHS reforms

‘Fundamental rethink’ needed to steer ‘messy and fluid’ NHS transformation

Healthcare transformation is “multi-layered, messy, fluid and emergent,” stretching beyond just the need to change how a service operates and instead requiring a “fundamental rethink” to find better solutions.

These are the findings of a new King’s Fund report, which amassed the ideas and learnings recorded during interviews with more than 40 people directly involved in leading and delivering four successful transformation initiatives.

These included the Bromley by Bow Centre, a community organisation in East London working to improve health in a deprived borough; Birmingham and Solihull NHS Mental Health Trust, whose multidisciplinary RAID service is transforming liaison psychiatry across acute hospitals; Northumbria Healthcare NHS FT, whose purpose-built Specialist Emergency Care Hospital is changing emergency care; and Buurtzorg Nederland, a new care model that received international praise for its cost-effective, nurse-led approach to community care.

The think tank’s research found that, above all, there are groups who work “tirelessly to achieve great things.” But nevertheless, there are still key considerations for health and care leaders currently working to achieve large-scale, transformational change.

One of the major observed challenges was the need to overcome inertia by creating a more receptive context. “Our stories show that staff working in health and care are very motivated by a vision of safe care, better ways to deliver quality, or simply ‘improving a day at work’,” the report wrote. “But they also show that many people do not feel able to act as the change leaders in our stories did, to do things differently.

“Staff described a sense of wanting to act but feeling unable to, thus contributing to inertia and preserving the status quo. Our advisory group quoted Martin Luther King Junior to sum this up: ‘We are confronted with the fierce urgency of now’ and yet so few large-scale transformations have happened in health and care to date. This warrants further study to understand and address the underlying barriers.”

There are also barriers within the system that proved to be disempowering, such as clashes between different sectors of the health and care landscape. ‘Old power’ – held by a few, closely guarded and inaccessible – often collided with ‘new power’ – enabling people at a grassroots level exercising agency.

“There were also examples of shifts from old to new power in the stories, but these were limited; some power clashes were still impacting services and relationships many years on, showing how hard it is to shift deeply ingrained mindsets,” the report explained.

Responding to the report, Dr Mark Spencer, co-founder of NHS Collaborate, said there are many “truly great” things about the health service, but some elements, such as the leadership culture, have to change.

“The historic top down hierarchical system which, at best seeks to micro-manage, and at worst verges on bullying, has to change into a culture based on understanding and compassion, added Spencer.

“Only then will we be able to establish relationships that are built on trust, and go on to bring about the sustainable transformation that the NHS so badly needs.”