The Changing NHS

 

I've just finished working on a set of strategic scenarios that describe four 'edge of plausibility' possible futures for Health and Wellbeing systems. The work was commissioned by NHS North West and the detailed scenarios can be downloaded from their website.

The scenarios are titled; Corporate Cures, Community Cures, Shopping for Health and Living for Health. They have been developed, over the course of 12 months, involving nearly 400 NHS managers and clinicians, local authority senior officers and Councillors, MPs, 3^rd sector leaders, private healthcare leaders etc.

The rationale for the work, basically, is that NHS strategy making is sometimes too narrowly-focused and short-term in nature. Senior leaders (national and local) often assume that the NHS is sufficiently powerful to exert a dominant influence on its’ strategic operating environment. Unfortunately this assumption is proving less likely as a number of fundamental drivers bring stronger pressures to bear over the next 10-15 years. These drivers include:

1. Approaching the limits of the welfare state (expressed through a more solid public consensus about the ‘tax take ceiling’)
2. An explosion of new treatment and diagnostic possibilities
3. An ageing population; and
4. Increasingly sophisticated and demanding forms of consumerism

Building and using strategic scenarios is one way of helping leaders explore possible ways of coping/thriving in the light of these drivers. Hopefully NHS organisations can use the scenarios to help them improve the far-sightedness of their local strategies. Essentially by:

1) mentally immersing 'strategists' in the 4 future ‘worlds’ that depict, in differing ways, how English Healthcare and Wellbeing systems might evolve through to 2020; and

2) subsequently ‘returning to the present’ to discover a) new or sharper insights into what strategies might be appropriate over the next few years or b) new insights into how robust existing strategic intent is and what conditions might trigger it being re-thought. 

Anyway, we will see, as local Trusts and PCTs start to use them. 

nhs

strategic scenarios

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? 

nhs

Darzi

implementation

How do non –executive directors add value to strategy making in the NHS? Last week I heard two quite contrary views about this, both expressed by senior NHS managers.

1. Constructive Critics

In the first view, strategy making is seen very largely as the responsibility of executive teams. Non-execs don’t have the time or knowledge to engage in this process. Instead they can best add value by reviewing and constructively questioning the strategy (once largely formed). They might help the executives to ‘fine-tune’ around the edges but it's unlikely that they would push for a strategy that the executives were unwilling or reluctant to contemplate and in any event, by the time they are involved it's too late to have a fundamental rethink!

2. Active Shapers

In the second view, non execs are seen as central to the strategy forming process. Because they come, largely, from ‘beyond’ the NHS they can often challenge assumptions and values-led suppositions about what the strategic intent ought to be. This is especially true for non-execs who have spent time in customer facing large private businesses. In short, they can help executives to think way beyond their 'comfort zones’ and encourage the crafting of new strategies that enables the NHS to more fully enagage with the world as it is rather than how it ought to be.

So, here we have 2 quite different views about how non-executives can help NHS organisations form far-sighted and effective strategies. I suspect the first view holds sway in most places but perhaps the second is the one which holds out the prospect of creating most value.

Do you recognise the two roles I've described and what are your non-execs, constructive critics or active shapers?

nhs

non-executives

strategy

Somewhat belatedly, I’ve just read the interim Darzi report, called ‘Our NHS, Our Future’, published earlier this month. The report recommends a range of actions intended to help the NHS move, during the next 10 years, from an improving system to a world class system.

The recommendations fall under 5 headings and these headings are suggested as the cornerstones of a new Vision for the NHS over the next 10 years. They are:

• A Fair NHS (improved access for disadvantaged groups, increased productivity, good outcomes for all etc)
• A Personalised NHS (more integrated care, more dignity, choice and personal control for patients, improved consumer responsiveness and access again!)
• An Effective NHS (faster adoption of new technologies / innovation, more integrated and evidence-based care pathways, a sharper focus on outcomes achieved etc)
• A Safe NHS (stronger regulatory powers to inspect and intervene, MRSA screening on admission, financial penalties and incentives linked to cleanliness of Wards etc)
• A Locally Accountable NHS (a clearer and more streamlined process for effecting big service changes, better leadership more often from clinicans and possibly a new/revised NHS consitution)

You can get hold of the interim report here (58 pages, pdf).

Stage two of the review, runs from now to June 08 and is more devolved in nature. Basically each Strategic Health Authority area has been instructed to set-up clinical review groups to make detailed recommendations about the future shape of eight areas of activity. These are:

• Maternity and newborn care
• Children’s health
• Planned care
• Mental health
• Staying healthy
• Long-term conditions
• Acute care
• End-of-life care

My guess is that given the membership and focus guidance given to the clinical review groups, the sum of all this work will add to or strengthen the recommendations associated with An Effective NHS in particular.

My initial reaction to the interim report is:

1. Overall, the report is clear and contains a number of very sensible recommendations, especially in relation to access to primary care services
2. The Locally Accountable NHS element is the weakest by far. There is nothing very exciting or visionary here with regard to the NHS’ relationship with local government or local people. Will the NHS ever be brave enough to seriously explore options and ideas in this regard?
3. The Personalised NHS element of the Vision, if pursued vigourously, is likely to conflict directly with elements associated with A Fair NHS and An Effective NHS. Under Blair I’d have expected the tensions to be resolved in favour of a more personalised NHS, but now I’d go the other way and suggest that ultimately the personalised element of the Vision will be ‘held in check’ in-order to allow the other two elements to take centre stage, especially the ideas associated with a Fair NHS. That’s what defines Brownism in my opinion.
4. Because exploration of funding options was ruled out before the review started, there are some big questions left untouched by the review process, especially in regard to how the extension of personal-budget holding might ‘play out’ over time.
5. The idea of a new/revised NHS constitution is potentially an important part of the process that could open-up a much needed national debate about the kind of health and wellbeing system that might benefit the country in future. Let's hope it does not, instead, turn into a self congratulatory 60^th birthday present.

What do you think about the interim report?

by Jeanne Hardacre - Guest Blogger

A couple of weeks ago, I happened to be sitting at a lunch table at an event with a very senior manager who works in a very large NHS organisation in a very large city in the UK. She manages a very large budget, has a very large number of staff and works very long hours. She told me of the very positive feedback she regularly got from her boss, the Chief Exec, about her achievements and potential.

I hadn’t met her before, but I could tell straight away that she had very big ambition. Soon, she confirmed it; she thought she could do a Chief Exec’s job in a few years’ time, maybe when she was about 40. She was looking at moving to a new Board-level job soon. Very good.

Then came the very small stumbling block in this person’s career plans. Her boss, the very complimentary afore-mentioned Chief Executive. When hearing of this manager’s intention to leave the trust, her very flattering feedback turned into very scornful criticism. Very personal attacks. Very belittling remarks. Frankly, very bitchy behaviour.

Not very becoming of an experienced NHS leader, huh?

But with her very large network of contacts, her very long CV, her very inflated ego, and her very serious threats to limit this person’s career if she dared to leave the organisation, she viewed herself as entitled to control this manager’s life choices.

How very dare she?  Well, she can, she did and she probably will do again. And nobody can stop her from treating her senior managers that way. Or can they?

There’s a fine line between a strong management style and bullying. Stress and work pressure can sometimes lead even the best managers to behave in unacceptable ways. Whilst the intention may to bring about positive results for the organisation, the impact on individuals can be erode confidence, shatter self belief, and lead to poor work performance – which isn’t good for them or the organisation.

If you’re aware of someone’s bullying style, you may feel that the only option is to stand by and wish things were different. However, doing nothing and accepting what is unacceptable condones the behaviour to other staff and effectively strengthens a culture of bullying within an organisation. This is known as ‘bystander apathy’ and can be considered the organisational equivalent of ‘watching a mugging on a daily basis.’

Whilst it may feel impossible to challenge senior managers in an organisation, there are ways of doing this constructively.

The Andrea Adams Trust, a charity which works to reduce the incidence of workplace bullying is a useful place to seek information about how to prevent or reduce bullying at work and this factsheet, in particular, is well worth a look.

Also, if you think you might be bullying people yourself, the Ban Bullying at Work campaign website offers a reflection questionnaire, specifically designed to help you challenge your preconceptions about bullying at work, and how your own behaviour might be perceived by your colleagues.

Go on, have a look. I dare you.

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bullying

leadership

If Foundation Trusts are to thrive then they need to be capable of building and sustaining a culture where clinicians and managers are confident, ambitious, competent and action-orientated. One aspect of this challenge is the extent to which Trusts can excel at spotting and nurturing potential future leaders from within their own ranks.

If a NHS hospital Trust employs, say, 4000 staff, then surely at least 100 future leaders are there somewhere? After all, that’s just 2.5% of current staff.

Does your Trust do this and if it does, do the Trust Chief Executive and the HR Director meet regularly to review how people in the ´group of 100´ are doing?, to plan what opportunities to offer people next? and to identify succession paths? 

If your Trust does invest in growing its’ own future leadership, what criteria is used to identify people? Perhaps your organisation uses the Leadership Qualities Framework, promoted by the NHS Institute for Innovation and Improvement?

Skip from Be Excellent™ has posted a list of eleven criteria for spotting future leaders, drawn from Ram Charan’s book: Know-How: The Eight Skills that Separate People Who Perform From Those Who Don’t

1. They consistently deliver ambitious results.
2. They continuously demonstrate personal growth, adaptability, and learning better and faster than their peers .
3. They seize the opportunity for challenging, bigger assignments, thereby expanding capability and capacity and improving judgment.
4. They have the ability to think through the business and take leaps of imagination to grow the business.
5. They are driven to take things to the next level.
6. Their powers of observation are very acute, forming judgments of people by focusing on their decisions, behaviors, and actions, rather than relying on initial reactions and gut instincts; they can mentally detect and construct the “DNA” of a person.
7. They come to the point succinctly, are clear thinkers, and have the courage to state a point-of-view even though listeners may react adversely.
8. They ask incisive questions that open minds and incite the imagination.
9. They perceptively judge their own direct reports, have the courage to give them honest feedback so the direct reports grow; they dig into cause and effect if a direct report is failing.
10. They know the non-negotiable criteria of the job of their direct reports and match the job with the person; or if there is a mismatch they deal with it promptly.
11. They are able to spot talent and see the “God’s gift” of other individuals.

Personally I think a list of eleven criteria is too many to ‘operationalise´ successfully. Instead I would focus on the five criteria that I’ve put in bold font. Also I’d add a sixth, along the lines of:

• They consistently demonstrate a strong sense of wanting to serve others, especially patients.

What do you think to this list? Does your Trust have a way of identifying and nurturing potential future leaders? Does it draw equally from clinical and managerial ‘gene’ pools?

Thanks to George Ambler at The Practice of Leadership for drawing my attention to this issue.

Steve

nhs

leadership

The NHS currently has 65 Foundation Trusts (FTs), employing approximately 220,000 staff. The idea is that these organisations, usually secondary care acute providers, freer from central control, will be both more effective and more active 'players' in helping to reshape the NHS provider landscape.

In an earlier post I talked about 4 strategic mindsets that FTs might hold. I’ve now 'polished this up' a bit and so I'm re-posting, as I think the mindsets, as described in this post, are more accurate.

The 4 mindsets are not all mutually exclusive but I wonder how well a FT can pursue more than one of these successfully at the same time. They are as follows:

1. Compete with ‘Look Alikes’
This mindset is often the most prominent one amongst managers at the outset of a Trusts’ journey to FT status. Usually, by the time the application process is complete, views have migrated to number 2 below, but some still retain this mindset and many may well return to it once they feel more confident. Here, the FT continues to seek to provide a comprehensive range of local services whilst also growing quickly by winning market share from neighbouring acute trusts that are believed to be in a weaker position in certain service lines. To do this well it needs to act quickly, before other Trusts get their act together and before PCTs become better at ‘market’ management.

2. Refocus on Core Business
This is the most common mindset to be adopted once a Trust becomes a FT. Driven, in large part, by fear of becoming financially unstable and thereby falling foul of Monitor, the independent regulator, this type of FT quickly decides to stop pretending that it can be good at everything and seeks to re-focus on what it is good at or can produce a surplus from. To do this well it needs to be single minded in seeking to earn a deserved reputation for providing certain services that might, ultimately, lead to higher volumes of core business, possibly via brand extension into other FT and private sector facilities.

3. Be Entrepreneurial
Here the new FT wants to get off the mark quickly by enthusiastically seeking out large numbers of opportunities for creating or contributing to new services and/or niche businesses, often beyond its current portfolio of activity. ‘Let a thousand flowers bloom’ might be the motto. Managers within this kind of FT operate within an earned autonomy regime and, even if only a few ideas are ultimately fully supported, this should quickly give the Trust an interest in several new ‘businesses’. Some of these can then be sold off as going concerns, raising significant income. Ultimately the Trust will probably become a holding company with several operating divisions or it may merge with other FTs.

4. Dive Deeper
Here, the FT believes it can use its resources and talents to help the local health and social care economy become more coherent and efficient. Accordingly, it seeks to exert more influence within the local primary and social care sectors. In its most developed form this mindset suggests a high degree of vertical integration, with groups of GP practices contractually aligned to the FT and community service staff and possibly some local authority staff employed. Ultimately this mindset suggests an FT will have an interest in investing in new sub-acute community-based services, especially those that serve older people with complex co-morbidities, perhaps in partnership with new private sector providers.

Do you recognise these mindsets? Are there others around?  To what extent do you think a FT successfully pursue more than one of these mindsets at the same time?

Steve  

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hospitals

strategy

If you could change 5 things about how the NHS is led and managed what would they be? An American reader emailed this question to me yesterday and I've been mulling it over this evening, during a train journey to Edinburgh.

Here's my top 5 (for now at least):

1. I'd invite all Trust, PCT and SHA Boards to consider reappointing all Chief Executives for a minimum of 7 years now;
2. I'd insist that HR Directors had the achievement of productivity improvements  listed as their number one priority in their job descriptions;
3. I'd set one target for acute trusts. To reduce the mean amount of time it takes a qualified nurse to respond to a patient's call for attention at the bedside;
4. I'd ask all PBC groups to disclose whether they are proposing to offer comprehensive access to NHS funded health check-ups to people over the age of 25 and if not, why not;?
5. I'd expect all managers to  participate in a development programme that has but one aim. To encourage participants to take more responsibility for getting things done rather than spending time re-framing the problem and sharing their analysis with senior colleagues.

Quite a little centralist aren't I? Do you think Gordon Brown's Advisors are reading this?  Nope? I don't think so too. I wonder what his list might be?  For that matter, what does your list look like?

Steve

nhs

gordon brown

YouGov has just released the results of their latest poll on ‘Whom Do the Public Trust?’

First the good news, NHS hospital managers are more trusted to tell the truth than Estate Agents. Yes, that really was the good news. Now for the bad. Out of 25 professional groups, NHS hospital managers are 18^th in the list, behind Trade Union leaders, Plumbers and Journalists on the Daily Mail. Now the really bad news, NHS hospital managers had a trust rating of 36% in Feb 03 and now it’s down to 17%. A fall of 19% in 4 years.

See the full results here.

What level of trust is it realistic for NHS managers to aspire to achieve, given the magnitude of change occurring in the NHS? Should they accept that, inevitably, it will be low and that’s just the price to be paid for pursuing radical change?

If a CEO wanted to improve their local rating what might they do? Perhaps they need to strike a good balance between focusing on a) building a positive personal profile; b) sharing good news stories about services that need to remain largely as is and c) sharing information about unsafe or unsatisfactory services that really ought to be subject to concerted public pressure to change?

How about a reputation management plan that includes:

1. A weekly column in a valued, widely read local paper
2. A regular online Q&A service, perhaps arranged through local schools and colleges, with the replies uploaded to YouTube so people can put a face to the 'suit' giving the replies. (Have you seen WebCameron and Patricia Hewitt's YouTube appearances?)
3. Open Days, where NHS managers host members of the public, show groups around new facilities and explain how services are changing
4. Public consultation processes that start without any pre-formed ‘options’ being promoted

What other ways might managers seek to rebuild trust or perhaps they shouldn’t bother to try?  Instead managers could accept being untrusted as ‘par for the course’ and rely instead on trying to persuade clinicians to ‘front’ difficult changes. After all, GPs (family doctors) got a 89% trust rating in the YouGov poll. Only down 4% from 4 years ago.

Steve

trust

professionals

nhs

In Made to Stick, Dan and Chip Heath explain why some ideas take hold and others quickly fall by the wayside. In summary, they suggest adhering as much as possible to 6 principles help make ideas ‘sticky’. SUCCESs stands for Simplicity, Unexpectedness, Concreteness, Credibility, Emotions and Stories. The ‘stickier’ ideas reflect more of these principles. There’s quite a bit more to it than this but that is the 'gist'.

In an earlier post I wondered why NHS Mission or Vision statements have so little use as managerial tools for aligning and motivating staff. I think the Heath brothers have just helped me out.

Here’s a couple of Vision statements I found from two NHS Trust sites (picked at random, honestly) and two alternative versions that might be ‘stickier’.

Old Version

We will ensure the Leeds Teaching Hospitals NHS Trust is a locally, nationally and internationally renowned centre of excellence for patient care, education and research. We will deliver this vision by ensuring we attract the best possible staff and invest in their development.

New Version

The NHS employs 1.3 million people. Our 15,000 staff will be amongst the best there is and that's why Leeds Teaching Hospitals is talked about in 193 countries.

Old Version

To be the first choice for patients, offering access to high quality patient services. We will build on our success as an NHS Foundation Trust, continually developing services to meet the needs of our patients, working with partner organisations and staff to strive towards excellence. We aim to be an organisation that the community can be proud of, responding to the views of patients, members and staff.

New Version

People will choose to use our services more than 200,000 times every year. That’s because we make sure we know what local people want and we make sure we provide it.

I think these versions are simpler, more unexpected and more concrete and credible. What do you think? Are these newer versions 'stickier'? , More meaningful for staff? Would they be more useful in helping staff figure out what to do and how to behave?

Steve

nhs

vision

change management