The NHS 'safe harbour' paradox

There is a conundrum at play in the world of NHS transformation. We hear from leaders of great health systems who have journeyed through the transformation ‘pipeline’ about some of the things that characterised that experience: sustained effort; incremental change rather than big bangs; trial and error; periods of reduced productivity.

At the Nuffield Trust Summit, Dr Bob Wachter (University of California), an expert in introducing clinical information systems, described the technology paradox. This is a period of reduced productivity that follows the launch of any new IT system while people learn how to use it. He explained that the real gains come when people have become used to the new system and start reimagining the ways in which they work with it.

Professor Richard Bohmer reminded us of the need for different forms of leadership at different levels of an organisation. He argued that data which are turned into meaningful information alongside explicit goals and a clearly articulated narrative for better care are essential to change clinical behaviour. He also emphasised the importance of trial and error; and the need to accept the fact that some initiatives won’t work, and this is not an insurmountable problem. These suggestions complemented the presentation by Professor Huw Davies, who described significant differences between the perceptions of hospital chief executives and clinical directors in relation to their ability to influence change and the level of support available.

At last year’s Nuffield Trust Summit, Dr Brent James of Intermountain Healthcare described how Intermountain’s quality improvement over the last 20 years has been the result of many small, well-executed initiatives rather than a single grand plan.

So how does this fit with the concept of a ‘safe harbour’ raised during the Summit, into which aspiring, transforming English health and care economies can navigate in order to calm the choppy waters of their transformation journey? It seems the deal is that the leaders of a health economy can develop a transformation plan backed up by a business case and, after some hard negotiation with people higher up the NHS and regulatory hierarchy, the rules of the safe harbour will have been set. Some slack and wriggle room will have been created.

But what will this wriggle room look like? Will a year or two of deficit within a proposed four- or five-year contract be allowed? What about missing a couple of targets? Or a decline in the Friends and Family Test score? And what if the wriggle room is used up when one part of the plan develops unexpected glitches, and a year later it looks as though it won’t deliver what was promised?

In one sense, the quid pro quo of admission to the safe harbour should be an obligation to deliver whatever has been promised. But that suggests that what is needed is brilliant execution of a detailed and perfect transformation plan – no slippage against the timetable; no glitches, no mistakes. This is a far cry from the wise words about trial and error; having a good honest go while expecting that some things will fail; technology paradoxes and re-inventing the work once the new kit is more familiar to staff.

One chief executive at this year’s Summit described playing the role of liaison officer between an acute trust board and the regulators. Elsewhere, other CEOs have described the experience of life on the receiving end of performance management by the NHS hierarchy. It rarely sounds very forgiving.

Many lessons can be learned from the combined wisdom and experience of those mentioned above, and from numerous other health systems that have transformed care through long-term improvement programmes. As it stands, the chief executives of NHS organisations seeking fundamental transformation may do better looking for a nuclear bunker than a safe harbour.