Decisions about money, staff and reorganisations in the NHS often steal the headlines. But the real test of a plan is the much less nationally visible question of whether it changes the day-to-day behaviour of NHS staff. Does it succeed in genuinely getting front-line workers behind changes, encouraging effective leadership, and bringing people together to tackle common problems?
Success requires front-line staff and local leaders to behave differently
Attitudes and relationships are particularly important when the changes desired involve working across different organisations: bringing together GPs and hospitals, and the NHS and social care, to create systematic improvements. This has been a national priority for years and is likely to remain one. While the main policy goal is to make front-line staff work better together, it is also essential for the national policy that those who lead collaborating organisations are supportive of planned changes; that they sign up to shared goals; and that they are willing and able to make compromises about their own organisation’s outcomes.
The Advancing Quality Alliance ran system improvement projects in the north of England for many years. A study of their work found having ‘the right types of leaders’ to carry out complicated changes across multiple organisations – people who coped without hierarchy and co-operated for the long term rather than undercutting other local organisations – was paramount. There needs to be ‘distributed leadership’ where staff at every level take the initiative to improve or transform care. This means a clear ‘common goal’ is needed that is widely shared and understood (Fillingham and Weir, 2014).
When these relationships are lacking, the consequences can be serious. A recent Care Quality Commission report on older people being passed between health and social care found that areas without good relationships and shared goals between executive leaders experienced problems including refusal to share data with other services, patients being sent to the wrong place, and attempts by services to blame each other for problems. Patchy progress had been made despite an array of national initiatives aiming to integrate care during this period (Care Quality Commission, 2018).
Research into high-performing US health systems that were succeeding at improving care for long-term illness demonstrated that good relationships and common purpose are vital within organisations too. This means senior leaders must have a good relationship with both the front-line workforce and their executive colleagues, and clinical and non-clinical managers must work well together. In case studies of successful US provider organisations, clinical leaders barely recognised a distinction between the roles of doctors and managers (Dixon and others, 2004). Unfortunately, a much more divided ethos is common throughout the NHS (Dickinson and Ham, 2008).
What can national policymakers at the centre put into an NHS plan that makes these attitudes and behaviours more likely to emerge? One obvious conclusion is that a national plan needs to be something that can form a ‘common goal’ for NHS workers, clinicians and managers alike. The goals of reform should be wrapped into a coherent narrative that explains and justifies the experiences of staff living and working through the period of change.
This means listening to staff and reflecting their values and motivations in the targets that are selected. The plan should not feel like a transmission of political priorities into clinical work. It means being careful about relying on managers to win over or control clinical staff, which risks emphasising the divide between the groups.
One approach likely to help create a narrative that staff can get behind is to involve them in actually designing reforms, as was done with the 2008 strategy High Quality Care for All. This was based on more than 2,000 clinicians and other front-line staff meeting locally, agreeing ‘visions’ and then feeding these in to the central review team (Department of Health, 2008). However, in many other reforms such as the initial introduction of the internal market, both front-line staff and the academics and organisations that work with them have barely been involved in policymaking (MacKillop and others, 2018). While this can be because of legitimate worries about their acting as vested interests, the risk of ending up with changes that cause unnecessary disaffection should also be considered.
History also provides two more specific lessons about how to make policies staff are willing and able to follow.
Don’t make it more complicated than it needs to be
Health Action Zones were partnerships between different agencies in disadvantaged areas, a national policy rolled out under New Labour in 1998. They aimed to understand health needs, improve the responsiveness of services, improve health and reduce health inequalities.
Academics hired to evaluate them by the Department of Health later made some useful observations that pertain to the ability to engage people and maintain their involvement in an article entitled ‘Lessons from a policy failure’:
“Too many hugely ambitious, aspirational targets were promulgated. The pressure put on local agents to produce ‘early wins’ was debilitating. A sense of disillusionment began to set in relatively early in their lifespan.” Judge and Bauld (2006)
By 2003, they had been abandoned. Ambitious targets required by the centre were intended to galvanise local staff and leaders, but by going so far as to be unachievable, they ultimately led to the opposite. There are signs that this risks being repeated in the recent Sustainability and Transformation Plans, which have complex and ambitious goals assuming reductions in activity that may be impossible (Ham and others, 2017).
The NHS Action On initiatives, which aimed to reduce waiting times and increase access to the best treatments in areas like cataract surgery, hip and knee replacement and dermatology offer a contrast. They were much more focused in their ambition and with a narrower range of stakeholders to be involved in design and implementation (NHS Executive, 2000; Roland, 2005). Several elements proved successful, and waiting times fell sharply.
Evidence from our studies of clinical commissioning groups, introduced under the 2012 Health and Social Care Act to plan and fund care locally, found several factors tended to erode the initial enthusiasm of clinicians. These were a lack of autonomy to take decisions that meet local needs; a lack of funding for research and advice to support decisions; and a lack of support from the NHS hierarchy for tough decisions about priorities or rationing (Robertson and others, 2016). This suggests giving local areas more capacity and responsibility to set their own goals and decisions could help maintain engagement and collaboration over time, which is crucial to getting through an often slow start-up phase to longer-term benefits.
Don’t just talk about freeing up time, actually do it
There is plenty of evidence about the processes through which the working relationships, shared processes and shared goals needed for effective integration can be built. Evaluations of the care trusts which brought together community services and hospitals in the last decade demonstrate that more is needed than simply putting people in the same building or organisation (Glasby and Dickinson, 2008). As Richard Bohmer (2016) has noted, for genuine transformation to occur there needs to be sustained change in individual behaviour, team interactions and design of operations. Techniques for this “relentless hard work” of redesign include getting staff and patients together to design services from a starting point of what is needed, and ‘action learning sets’, which are regular meetings to jointly discuss problems, suggest solutions, and go over whether they have worked.
One important role for policymakers is to recognise that these take up significant time from front-line staff who have little to spare. With workforce shortages, funding shortages, growing waiting lists and rising patient expectations, finding this time is very difficult, and national plans must take account of this. In the context of establishing US accountable care organisations, US academic Elliott Fisher (2013) equated the stresses of coping with change while continuing with normal activities as “remodelling the house while you are still living in it”. Some nationally supported projects, like the ‘Primary Care Home’ initiative, did include specific funding for this – but the amounts were not large, and our evaluation still found that leaders struggled to find the necessary time (Kumpunen and others, 2017).
The NHS Vanguard sites received significant funds to ‘back fill’ this kind of development time. This is positive, but it sets a precedent where a small cluster of sites might be picked out for additional funding, while the majority will have to achieve integration with few additional resources and for these the options are limited.
One possibility would be to negotiate in advance reductions in performance (along with a proposed recovery line) associated with creating time for professionals to participate in designing and implementing changes. Another might be to reduce the range or intensity of services provided by staff who are involved in designing and developing integrated services.
In a national health service funded by the taxpayer, big decisions about the direction of travel will always tend to be taken at a national level. But this is a service based on human contact, with a high level of professional discretion for its skilled staff. If leaders in the NHS forget that changes actually consist of millions of small behavioural changes on the part of staff, they should not be surprised if the levers they pull sometimes feel as if they are not attached to very much.
Bohmer R (2016) ‘The hard work of health care transformation’, N Engl J Med 375: 709–711
Care Quality Commission (2018) Beyond barriers: How older people move between health and social care in England. www.cqc.org.uk/sites/default/files/20180702_beyond_barriers.pdf
Department of Health (2008) High Quality Care for All. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/228836/7432.pdf
Dickinson H and Ham C (2008) Engaging doctors in leadership: Review of the literature. AMRC, University of Birmingham and NHS Institute for Innovation and Improvement. https://www.birmingham.ac.uk/Documents/college-social-sciences/social-policy/HSMC/research/engaging-doctors-leadership.pdf
Dixon J, Lewis R, Rosen R, Finlayson B and Gray D (2004) Managing Chronic Disease: What can we learn from the US experience? Report, The King’s Fund. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/managing-chronic-disease-what-can-we-learn-from-US-experience-publication-dixon-lewis-rosen-finlayson-gray-1-january-2004.pdf
Fillingham D and Weir B (2014) System leadership: Lessons and learning from AQuA’s Integrated Care Discovery Communities. www.kingsfund.org.uk/sites/default/files/field/field_publication_file/system-leadership-october-2014.pdf
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Ham C, Alderwick H, Edwards N and Gainsbury S (2017) Sustainability and transformation plans in London: An independent analysis of the October 2016 STPs (completed in March 2017). Report, The King’s Fund and the Nuffield Trust. https://www.nuffieldtrust.org.uk/files/2017-09/stps-london-kings-fund-september-2017.pdf
Judge K and Bauld L (2006) ‘Learning from Policy Failure? Health Action Zones in England’, European Journal of Public Health 16(4), 341-343.
Kumpunen S, Rosen R, Kossarova L and Sherlaw-Johnson C (2017) Primary Care Home: Evaluating a new model of primary care. www.nuffieldtrust.org.uk/files/2017-08/pch-report-final.pdf
MacKillop E, Sheard S, Begley P and Lambert M (2018) The NHS Internal Market. University of Liverpool.
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