The Changing NHS

 

A friend rang me today asking for a favour. She is the Chief Exec of a large public service organisation (not in the NHS) and was due to run a 3 hour session next week with her direct reports. The meeting was to 'get a fix' on what kind of organisation they want to become over the next 5 years. The vision thing if you like. Did I have any ideas?

This is what I suggested:

Imagine it’s 5 years in the future (2013) and org x has become the kind of organisation you really want it to become. It's been an incredibly successful 5 years. As a group, pick out 6 or 7 questions from the list below that appeal most and then, in turn, tell colleagues what the answers are. Capture the most salient or intriguing points made on a flipchart.

1. Who are the main stakeholders of org x in 2013?
2. How do you work with them?
   
3. How do you produce value with them?
   
4. What are the most influential trends in your industry?
   
5. What is org x's image and reputation?
   
6. How and with whom do you compete?
   
7. Who are your major customers now and how are they helping to make the organisation succesful?
   
8. What is org x's unique contribution to the world?
   
9. What is the most important impact your organisation has on the local economy ?
   
10. How do you make money?
    
11. What does org x look like?
    
12. In what ways is org x now a really great place to work?
    
13. Why do customers love org X?
    
14. What is org X's most significant contribution towards making region y a great European destination?
    
15. Why do you personally love working for org x?
    
16. When your kids ask you what you do for a living what do you tell them?

Review the points that made it to the flipchart. How can you state the essence of these aspirations in a compelling way? Express your new Vision so that it is:

• succinct;
• unexpected;
• seen as credible; and
• has a big emotional pull

Now, return to the present and take a hard look at org x as it is now. How do you need to change? List the 5 most important changes you, collectively as a team, need to help the organisation to make.

What do you think about this process and the questions? What questions did I miss? Which ones do you really like and why?

nhsvision

 

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. 

nhsstrategic scenarios

One feature of a new confident NHS, an NHS capable of creating its’ own future, will be organisations that are capable of making strategy for themselves.

Too often, what NHS managers see as strategy making is really a sort of meta-tactical discussion. The thing being explored will probably happen – its’ really just a question of how it gets implemented. Important yes, but not really making strategy is it?

If you don’t believe me try using the impact/uncertainity grid (shown above).

Brainstorm all the big issues that face your organisation over the next 10 years and then place the issues on the grid. My guess is that most of the issues you spend time ‘strategizing about’ are in the bottom right hand side of the grid. Yes, they are potentially very impactful but, relative to some other big issues, they also are much more likely to happen. It’s really just a question of how they are implemented.

What about the big issues in the top right hand side of the grid? The ones that are less certain to happen. Do you talk much about these issues? If not, why not? Are they in the ‘too difficult’ box? Or perhaps you think they’re in the ‘not something we can do anything about’ box?

However, if you’re going to become an organisation that really creates its’ own future then your going to have to get comfortable exploring these less certain possibilities.

Steve

nhsstrategy

I've not posted for the last couple of weeks because I've been 'flat out' working on a scenario building project in the North West of England.

Initially, this has involved me and colleagues listening, on a one to one basis, to more than a hundred NHS and Local Authority CEOs/ Directors, MPs, and clinicians describe what a successful health and wellbeing service might look like in 2010 and 2020. It now involves running a series of  workshops that enable people present to begin to build sets of scenarios, using questions and themes drawn from interviews as a starting point. 

Explicitly using the scenarios comes later in the year, via a second series of workshops where we help decision makers to:
a) test out the robustness of current and future strategic intentions and
b) help discover new strategic options for flourishing in the future

I don't have time (or client permission for that matter) to go into any detail about the workshop process and the shape of the scenarios that are beginning to emerge. The team should have something useful to share with the client in the Autumn and hopefully I'll be able to share some of this material at some point, but suffice to say some interesting stuff is already happening.
 
In particular, on a general level, I was struck by how, at the first scenario building workshop, the people present, (all senior NHS and Local Authority managers and clinicians), were very easily able to recognise that there are some big, important issues and questions that ought to exert significant influence on a set of plausible challenging scenarios. Questions about technological and pharmacological developments, societal attitudes to health and wellbeing and environmental sustainability, macro-economic pressures etc.  But, and its’ a big but, at the same time many of the same people also felt personally very uncomfortable when trying to contemplate working in these possible new worlds, mainly because the new worlds challenge conventional wisdom about:

i)   what managers and clinicians do; and 
ii)   the amount of power patients and citizens should hold and how they might exert it to get what they want.

Also, the scenarios depicted worlds that are, to quite a degree, very difficult ones for managers and clinicians working in today’s NHS to reconcile with their personal values. 
 
Perhaps this is an important aspect of what good scenarios should do? Namely, help decision makers contemplate how they might operate in futures that they otherwise would largely fail to entertain as plausible possibilities. But, even if this is true, I'm struck at how big a psychological barrier exists and unsure how we might help people begin to 'walk down the beach, put their toes in the water and then stay in there rather than running back straight away, screaming "the waters’ too cold".

How do we learn to face up to our demons? - Now that's a real challenge.

Incidentally, I'm also struck about how many ‘weak signals’ about these new worlds already exist in the present. Normally, I at least, seem to just ‘tune these signals out’ on a day to day basis. But once you begin to hold future scenarios in your head you begin to see lots of ‘acorns’ all over the place.  But that’s another story.
 
Steve
scenariosnhspsychology

I used the World Cafe process for the first time recently as part of a one day workshop design. If you're not aware of it yet, World Cafe is basically a process for encouraging deeper, richer conversations. The originators have a strapline - Awakening and engaging collective intelligence through conversations about questions that matter.

In a nutshell you arrange the room as a cafe - small card tables, paper tablecloths that people can doodle on etc - and anything from 12 to several hundred people discuss a key question in groups of 4. After 20 mins or so just about everyone gets up and moves to a new table for a conversation with new people (apart from one person at each table who stays behind as a table host to welcome the new 'guests'). 

It works with groups that range from 16 up to several hundred. You run the small table conversation process 3 times, with the same question being addressed each time and then harvest the learning in a whole group plenary discussion. The idea is that people build and make links to what has been said before at the table rather than make new/separate points.
 
If you want more info you can download a good concise guide here.  More information can be acquired at the World Cafe site.

The workshop was for Directors and aspiring Directors of Informatics. The key question was "What's the best contribution informatics professionals can make to helping local NHS organisations eliminate unnecessary (artificial) variation in service/operational processes?" 
 

Btw, if you're curious about the magnitude of unnecessary variation that still exists in the NHS have a look at the stats collected as part of the NHS Institute's Better Care, Better Value initiative. The data is here

 The process worked well, though when doing it again I would:

1. Spend some time with the group exploring what a key question might be, rather than presenting them with a suggested question and asking people if that sounded about right;
2. Have a 4th round of cafe conversations before the final plenary discussion, with a new question, something like "What have we discovered about how to make a more effective contribution?";
3. Ask table hosts, at the outset of each new table conversation, to invite new guests to add insights to 2 or 3 key issues that have surfaced in the previous discussion rather than asking them to summarise what has been said previously;

Anyway, what do you think? Does this sound like a process that could enrich some of your work with colleagues?

nhsworld cafelearning

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

trustprofessionalsnhs

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

nhsvisionchange management

“Forgive me father for I have sinned. I seem to have acquired some heretical beliefs about managing change in the NHS”:

Old – Smart NHS strategy is devised from skilful interpretation of policy

New – Smart strategy flows from strategic conversations with interesting, diverse people

Old – The best way to bring about needed change is to start quietly, where the context is most receptive

New – Be bold. Everyone’s watching for some signs that the political rhetoric of market led transformation is real. Small stuff will just get eaten up by the prevailing culture

Old - Effective leaders are emotionally competent, clinically aware and values driven

New- Effective leaders need to be courageous egotists happy to take huge risks

Old - The NHS is a core brand, trusted by the public. This branding will remain, regardless of which organisations provide services

New – If we’re talking brands, I’d like my surgery from Toyota, my primary care advice from John Charcol and my chronic illness managed by the Open University.

Feel free to confess....

Steve

change managementnhsOD

Rob Millard has a great post on his The Adventure of Strategy Blog called ‘Increasing Your Strategic Clock Speed’. Rob lists and expands on 10 ideas to reduce the time-lag between

a) the rate of change in the market;

b) the rate at which a firm can formulate a strategic response to those changes; and

c) the rate at which the firm can implement the changes necessary to execute the strategy.

His suggestions include:

1. Formulate Strategy with Execution in Mind
2. Broaden Participation in Strategy
3. Delegate Real Authority and Accountability
4. Focus Action on the Short Term
5. Get Good at Simplification
6. Think Scenarios, not Predictions …..read all 10 here.

Rob’s post got me thinking. These are great generic suggestions that the NHS should take on board, but are there any additional ideas that are particularly suitable to speeding up the NHS’s strategic clock speed? After all, in my experience, there is sometimes a 5 year gap between using new language that describes a strategic aspiration and actually being able to point at something tangible – this lag may be 10 years in the case of operating systematic and comprehensive Chronic Disease Management systems!

What about if:

1. You started a Strategy Salon. A weekly 90 minute drop-in where any clinician and manager can come along to informally explore the strategic implications of emerging NHS policy with the Chief Executive and other Executive directors. After all, strategy is the product of strategic conversations. Increase the number and quality of the conversations and you might improve and accelerate the development of strategy.

2. Strategic ambitions are prioritised and those not making the cut are dropped completely rather than described as ‘second order priorities’ (but everything is a priority I hear you say!) - There is a limit to any organisation’s capacity to deliver on new strategic ambitions and we need to get better at coping with this constraint;

3. Strategic ambitions are communicated to all staff in ways that help them to understand what is intended AND to translate this intent into practical implications for how they personally choose to spend their time - Too often the responsibility for implementation rests on a few, already overburden shoulders. In part this a cultural problem associated with delegation but it’s also related to how well strategic ambitions are communicated.

4. Scare talent is deployed to ensure that the most important initiatives are achieved. Every organisation has a handful of managers who are brilliant at initiating, leading or finishing projects. We need to make better use of our ‘Stars’ – They exist. That’s a fact. Let’s use them!

5. Incentives are offered for getting an initiative to successfully go live before a certain target date. Incentives could be financial but there are lots of other ways of incentivising brilliant performance. For example, teams that complete key initiatives ahead of schedule could be allowed to choose their next project for themselves.

Do these ideas appeal to you? Do you have other suggestions to increase 'clock speed'?

Steve

www.stevepashley.co.uk

strategynhschange management

I've just created my own little Amazon bookstore showing over 30 of my favourite OD, Change Management and Leadership books. I hope you find some interesting titles.

Do you have a book to recommend?

Steve

www.stevepashley.co.uk

bookschange managementOD