A key theme at our eighth annual Health Policy Summit last week was the approach to change in the NHS. The questions we now face are not about the development of new policy but how to create rapid change, improve productivity, reduce cost and cope with large increases in demand and expectations.
Listening to the debate and speakers at the Summit, there were three key themes that struck me as critical to the NHS at the moment. First, there is more to do to ensure that there is a clear and correct diagnosis of the problems. Second, there are uncertainties about the process through which change will be achieved. And third, these two issues combine with others to create a strong feeling of cognitive dissonance and a worrying mismatch between what people think, what they do and the real world.
Making the right diagnosis
While the Five Year Forward View set out the broad components of the direction at a national level in a helpful and powerful way, 18 months later the NHS is just starting to articulate the local version of this and trying to understand what this means in terms of cash savings and productivity improvements. While there is a national account of what the £22 billion required savings consists of and how it will be met, it is far from obvious how this translates into local action plans.
A previous attempt to plan by 93 clusters of CCGs two years ago was not a success, and it is not clear what is different this time when 44 clusters are going to attempt this in less time and, in some cases, with less experience of working together.
The explanation that this time their backs are really up against the wall, offered by one senior person at the Summit, seems to assume that: 1) they weren’t trying hard enough, and 2) the answer is there to be found. I am not sure that either of these are secure assumptions and it’s important to remember that trying harder when you are possibly doing the wrong thing is even worse than doing nothing.
Three speakers independently made reference to the work of Ron Heifetz who distinguishes between different types of change: technical change and adaptive change.
Technical changes are those with well-defined problems where the solution is known, can be found and the implementation path is clear.
Adaptive changes, on the other hand, are characterised by situations where the challenge is complex and to solve it requires transforming long-standing habits and deeply held assumptions and values. Adaptive changes also involve feelings of loss, sacrifice and anxiety; require new learning and new ways of thinking and relationships.
Many of the problems the NHS and social care system face are adaptive change problems. At the Summit, Robert Wachter highlighted the implementation of digital health technologies as one of these areas. There is a danger that we are treating adaptive problems as though they are technical ones and thereby massively under-estimating the skill and time required to deal with them.
The development of new models of care and many of the challenges the local systems are being asked to plan for are definitely in the domain of adaptive change, as highlighted by Richard Bohmer. This means that there are elements – particularly the formation of new working relationships and the redesign of complex systems that require time, negotiation, personal change and multiple experiments. There are limits to how far this can be accelerated. It also means that change based on copying or minor adaptations of other people’s models is very likely to fail.
Frontline staff, and particularly clinicians, need to be engaged in the hard work of making change happen but are under huge pressure, and are affected by what one speaker described as a ‘toxic industrial relations climate’. Research presented at the meeting by Huw Davies pointed out that there is still a significant gap between top leaders and clinical directors on key issues about change which mirror a similar disconnection found in the national staff survey.
This phrase was introduced to our discussions at the Summit at the opening keynote by Mark Britnell – and it kept reoccurring. People commented on the odd gap between the size of the problem and the degree of urgency. Another area of dissonance discussed centred around the rhetoric of transformation – with a desire for locally driven change contrasting with a strong focus on central grip and control. Similarly, there exists understanding that the changes being talked about are adaptive and take time, and yet the overwhelming message is about speed.
Candace Imison added a further example of cuts to education and training budgets while the idea of reshaping the current workforce is placed at the centre of plans for change. Anita Charlesworth noted the budget cuts to public health just as prevention was cited as a policy priority.
I suspect that the underpinning reason for this dissonance is that there is a growing concern that the solutions being proposed are inadequate for the size of the problem. The structure and governance of the system is a mess, but cannot be changed because the NHS probably cannot cope with another reorganisation and politicians have a phobia about further NHS legislation. More significantly, the UK is trying to buck a global trend – trying to care for a growing, ageing and more demanding population without spending any more money in real terms.
Cognitive dissonance is a worrying signal that something is wrong. Failing to resolve it causes anxiety and is likely to lead to poor decisions, stress and burnout. As those attending and following the Summit heard, we have quite a lot of that already.
Edwards N (2016) ‘Contradiction, change and misdiagnosis’. Nuffield Trust comment, 11 March 2016. https://www.nuffieldtrust.org.uk/news-item/contradiction-change-and-misdiagnosis