The Changing NHS

Soon, nine Strategic Health Authorities will submit their visions for the future of the NHS as the formulation phase of the Darzi review process comes to a conclusion.

As outlined in an earlier post, eight clinician dominated and led review teams have been busy in each SHA area trying to articulate what various ‘service lines’ might look like in the future.

So far so good. But how does the process move on from here? That’s the tricky question. Will PCTs and Trusts embrace the recommendations made by the review teams and happily fuse these aspirations into their own commissioning plans / service strategies?

Somehow SHAs have to construct an approach to implementation that does justice to the work done by CPGs whilst also respecting the strategic independence of PCTs and Trusts.

I’ve been involved, to a limited extent, in the Darzi process in a couple of SHAs and I know that SHA strategists have been preoccupied with this question for a while now.

On the whole, despite supportive noises when necessary, most PCTs and Trusts have been content to sit on the sidelines and wait to see what ideas emerge. Meanwhile, about 200 clinicians in each SHA area have been getting all fired-up, hoping to see the changes they have asked for, come to fruition.

If implementation hits a brick wall then this clinical enthusisam may soon disipate and worse, leading clinicians might become even more disilusioned with the NHS (and managers in particuilar who will probably be seen as the problem).

There’s no easy answer of course, but in thinking a bit about this ‘adoption’ problem I’ve been reminded about Chris Huxham’s work on Collaborative Advantage. Professor Huxham identified a few traits that successful strategic partnerships exhibit. In very short summary they are:

1. Have clear, common aims
2. Build trust, start with easier issues 
3. Use collaborative leadership
4. Be very sensitive to power issues
5. Carefully construct membership structures
6. Learn together 

I was minded to think about stategic partnerships because this is , in effect, what SHAs will be trying to construct or at least encourage, between the local Darzi review groups/SHA, PCTs and provider organisations.

For me, reflecting on these successful partnership traits provides some strong clues about what an approporiate architecture for implementation of Darzi might look like at the local level – or at least it suggests some principles that all parties might agree to abide by whilst constructing such an architecture.

The seven principles that come to mind are:

1. Implementation of recommendations to be managed via PCT strategic commissioning processes wherever possible (excluding those recommendations that can be introduced easily by clinicians acting under their own steam or require formal public consultation or changes to nationally constructed policy);

2. No PCT or Trust to have to implement any recommendation that they don’t support. The choice is local;

3. SHA to act as a ‘Process Agent’ on behalf of all CPGs, seeking to get as many of their recommendations as possible 'into play';

4. All PCTs to agree which recommendations that are adopting, refining or ignoring with the SHA Process Agent - together with phasing year by year. Not everything can be done at once;

5. Each PCT to nominate an implementation lead(s) (probably but not necessarily the person who is responsible for developing and overseeing implementation of Commissioning strategy or the part of it that pertains most closely to each of the eight CPG areas of focus);

6. Each Implementation Lead to meet with the relevant CPG quarterly for no more than 1 hour to share progress on adopted recommendations and seek CPG member support to help remove ‘blockages’ to implementation - especially via informal clinician to clinician peer pressure. This update process to be orchestrated by SHA; and  

7. SHA to fund and orchestrate voluntary learning sets to encourage implementation leads and CPG Chairs to reflect and learn together about how best to implement recommendations.

What do you think? Do these seem like useful principles?

What other principles might SHAs wish to consider to encourage effective implmentation of local Darzi recommendations? 

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