Beyond the blueprint: are bespoke solutions the future of the NHS?

It is obvious to the point of cliché that NHS providers are experiencing challenging times. But while some are struggling, others are faring better in this difficult climate.

Although similar problems (decreasing tariff levels, costly private finance initiative contracts and recruitment challenges to name a few) affect multiple providers, the consequences providers experience will vary depending on factors such as the state of the local health economy, and the shape of the organisation.

What makes perfect sense as a solution for one provider can seem utterly implausible or unfeasible to another.

Despite this diversity, NHS national policy imperatives have tended to aim for one universal answer to any specific problem. These solutions are implemented quickly across the board which makes it difficult for all of their objectives to be fulfilled all of the time.

The review will not fit all

The goals of the Dalton review, published today, are to disperse the excellence of the best more widely across the provider sector, and to encourage all providers to consider their long term futures. Sir David Dalton was adamant from the beginning that the review had ‘no intention’ of forcing change from the centre and that it would ‘not develop a blueprint of the future provider landscape or direct providers to a particular model regardless of local circumstances’.

Instead he has provided a menu of options and posed a question: at what point should a trust conclude that its present way of working is not sustainable and start to consider alternative organisational forms?

What can health learn from other chains

The Nuffield Trust contributed to the Dalton review by providing a report on lessons from other sectors for providers wishing to set up or join multi-site chains. We interviewed chief executives or very senior leaders from chains operating in a range of industries, from legal chains to nurseries.

The findings were interesting in terms of their potential lessons for NHS organisations wishing to work across multiple sites – one of the models in the review.

Those who had shifted from a single unit to a multi-unit model told us they had spent time establishing a corporate centre that performed very different functions (procurement, strategic human resources management, governance oversight) from their operating units. They had also developed internal audit functions designed to operate across distances and created sophisticated approaches to identify innovation across their sites and disperse this.

One of the most striking findings of the research was the extent to which these leaders felt that they were in control of their organisations’ destinies when making decisions about future plans. Interviewees told us they were able to say no to a potential acquisition if they felt the business case to be weak and there was a strong aversion to acquisition if staff in the unit to be acquired were not in favour.

NHS leaders that we spoke to also emphasised the importance of understanding the local appetite for change (including from commissioners) and highlighted the fact that major change requires significant management capacity – a message that I suspect our interviewees from other sectors would strongly support.

This analytical approach runs counter to the ‘burning platform’ analogy that has been cropping up in relation to provider sustainability in recent months, which calls for quick decisions in order to respond to existential threats.

Providers considering adopting new organisational approaches will need the thinking space to perform a careful diagnosis of their position and the options open to them, and to determine what support they may need to implement the changes they conclude are required. For those organisations not in immediate peril, crafting a realistic long-term strategy now could avoid the need for more drastic action two or three years down the line.

The broader value of the Dalton review

Although the Dalton review calls on the Trust Development Authority to reveal its intentions for the 93 trusts still in the foundation trust pipeline, the danger is that because the review does not spell out a solution for the most challenged trusts, it may be viewed as less helpful than if it had recommended an ‘off the peg’ approach.

But from a policy-making perspective, if we accept that different organisations experience the consequences of their shared challenges in different ways, then it makes sense to move away from the premise that a single policy intervention can provide a complete solution for such a diverse group of providers.

If the review can shift national policy expectations even a little away from the need for quick one-size-fits-all solutions and towards more focused and strategic local consideration of long-term challenges, then this will be an achievement in itself.