Who will deliver the productivity gains the NHS needs?

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Much of the conversation at the NHS Confederation annual conference has, as you'd expect, been about productivity. How is the NHS going to cope with increasing demand with very limited financial growth in real terms?

There are three key requirements that combined will make the absolutely necessary changes happen: will, ideas and execution.

There's plenty of will to change in the NHS, evidenced in the many conversations we've been having on our stand at the conference. The will is driven by a clear realisation across the NHS of the national financial position and the need to find about £15 billion of productivity savings.

There's also no shortage of ideas here. Almost every stand is offering some kind of solution, whether it's technological innovation, better approaches to workforce planning, how to make best use of data or how to organise clinical services. There is a vast national and international literature about best practice, and no shortage of case studies.

The third key requirement is execution, and that is where the real challenge lies. Despite the will to change, despite the endless case studies and examples, there is still huge variation across the NHS and no one organisation or health system is doing everything right. Joanne Watson, a consultant in diabetes and endocrinology, gave the Geoff Scaife memorial lecture at the conference today and said: 'the mediocrity of NHS care is not due to reluctance to change but to chronic inconsistency'. And that inconsistency must be tackled if the NHS is going to rise to the productivity challenge.

It is becoming clear that the scarcest resource in the NHS at the moment is the capacity to drive change, particularly when leaders are distracted by the kinds of organisational changes that strategic health authorities and primary care trusts will be facing.

Real change and improvement can only be delivered by frontline 'clinical microsystems' – that is the doctors, nurses and their teams – who make the majority of decisions on a day-to-day basis about how resources are used in the NHS. But these clinical microsystems need leaders who have the skills and the capacity to manage change. In the laudable goal of reducing management costs, we shouldn't throw the baby out with the bathwater by removing the leaders who’ll be able to drive and guide change.