How can we deliver the fundamental change needed to meet the challenges of the future?

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Part of Time to Think Differently

A big question, but just what are those challenges? The fundamental one is surely the need to move from an acute model of care to one based on the management of people with long-term conditions. This will require less emphasis on hospitals, and the creation of a new system of community care that is empowering, proactive and focused on the maintenance of health. At the same time, we know that the 'grateful generation' is being replaced by one that is quite rightly demanding higher standards of care, effectiveness, and safety.

This is not contentious, so why haven't we got it already?

I think it's because our current approach was designed to deliver something else. In essence this was quicker access, in response to some shamefully long waits on trolleys outside A&E departments and on waiting lists for surgery – clear measures, driven centrally and hard, with sanctions for non-delivery. This approach worked, as did the same approach for health care-acquired infection. But it brought with it a performance culture that was harsh and uncompromising, even bullying at times. It led to a culture that stifled innovation, and pressured and incentivised boards to focus on a narrow range of targets, leading on occasions to inappropriate actions that 'hit the target but missed the point'.

Crucially, this culture has created a misalignment, (or 'values divide') between managers and frontline staff, because targets have always been seen as 'political' rather than patient-centred on the shop floor. The resulting high level of staff disengagement is a significant barrier to progress.

Finally, Francis has reminded us that the priorities governed by targets are now out of date. The public worry more about standards of nursing, the lack of a coherent system of urgent care, and the treatment of frail older people. These have not been prioritised in the targets and have received less investment as a consequence.

So, what do we need to do differently? I propose six changes that I think would bring about the culture change that Francis referred to, and that is so urgently needed.

We need to free up the system to engage locally, to set local priorities, and to innovate in the interests of better care. This will mean accepting local variation, but it is a price worth paying for local buy-in, and for the innovation needed to create excellence.

We should mandate the measurement and publication of quality standards and outcomes by all providers, wider than – but including – the current measures, and without the target thresholds. The standard to aspire to each measure should be agreed through local consultation to match the locally determined priorities.

We should set up health maintenance services for people with chronic illness and measure the impact on their quality of life. Hospitals should be encouraged to set these up, because they have the specialist expertise needed and this will be the main role for many medical specialists in the future. They can then reduce capacity and reconfigure incrementally in a managed fashion.

We should take all the steps necessary to create open and transparent management of the NHS. Francis gives some leads, but there are others. Social media enthusiasts could contribute hugely in this area.

We should implement a new leadership style – at all levels – that incorporates a sophisticated understanding of societal wishes and views and is collaborative, and genuinely values-driven. In the new era, system interests will trump institutional ones, so there will be no place for macho leaders striving for narrow goals and empire creation. Our new leaders should understand the implications of Nilofer Merchant's 'social era'.

Finally, our leaders must create a compelling narrative on transformation that the public can support, so that our politicians can too. For too long we have criticised politicians for their lack of 'courage' while seeking their support for untrusted change proposals that have not been created through stakeholder engagement.

This is significant change, and it will take brave and courageous leadership to usher out the old era and bring in the new. Shall we get started?

Dr Mark Newbold is Chief Executive of Heart of England NHS Foundation Trust and Chair of the NHS Confederation Hospital Forum

Comments

Ed Macalister-Smith

Position
NHS Leadership Coach,
Comment date
07 March 2013
I agree that the "old" culture was at times bullying, and harsh. (Incidentally, despite all the mea culpa and hand-wringing at the moment, I see little sign of a new culture emerging...).

However, I disagree with the assertion that this led to a misalignment or values divide between Boards or executives, and front-line staff. This may have happened in some places, but it wasn't inevitable.

If it happened, it did so because leaders allowed it to happen. Those leaders may have been Chairs, or CEOs, or MDs, or DNs, or other executives, but any one of those groups should have been courageous and determined enough to stop that values divide happening. We shouldn't pass the buck for NHS failings up the line, it all happened on our watch.

...and of course we need to re-design the care system in the way that is described...

Hugh Rayner

Position
Consultant nephrologist,
Organisation
Heart of England NHS Foundation Trust
Comment date
07 March 2013
This is such a lucid and inspiring piece. I do hope you are given the space and support to realise your vision, Mark.
In answer to the comment from Ed, it may not have been inevitable but it needed exceptional people to absorb the pressure and protect frontline staff from the external culture. Many worthy managers and clinician leaders were used up in the process. As a result it will be harder to build the cadre of manager leaders needed to make the changes Mark so elegantly describes.

Mark Newbold

Position
CEO,
Organisation
Heart of England NHS FT
Comment date
08 March 2013
Thanks Ed. Wasn't meaning to pass blame upwards - you are right it is a collective leadership issue. But the message from the national staff survey is that it is a pretty widespread perception. I think we can all learn from this and do better in the future?

Jonathan Booth

Position
Director,
Organisation
Journey Management
Comment date
08 March 2013
It is very refreshing to hear someone in a senior leadership position within the system facing up to the challenges those of us on the outside have been trying to flag up for a while. More importantly, here are some clear and simple solutions to those challenges, rather than the defensiveness and excuses that we're all used to hearing. Well done!

The only thing I would add to the proposed solutions, or make more explicit, is to make a focus on delivering quality services for the public and patient the overall aim. This would soon address the values misalignment issue, which I believe is absoultely fundamental, and help to clarify the priorities that really matter.

Simran minhas

Position
Registrar in Anaesthesia,
Comment date
08 March 2013
I feel there is nothing to refute in what you have outlined but I remain at the younger end of my career, slowly witnessing how change lags behind eloquent principles in the NHS.

How do we address the fact that these principles are not embedded in the people delivering our services? They are the same people who have been delivering the target driven services and any other style of healthcare prior to that.

How do we become 'genuine'?

Geof

Position
Chair Social Care Retired,
Comment date
09 March 2013
In my 20 years as a councillor I can only characterise NHS management "As Management by Fear".
This has applied from Whitehall to individual units in our hospitals.

"You will increase your departments throughput by 10% and reduce your costs by 6%.

To which the very reasonable reply is:
"How do I achieve that"
" That is up to you, but if you cannot do it I will find someone who can"

Now I was always taught never to ask someone to do something that you cannot do yourself.

Changing the culture will be an enormous task, but setting local priorities will certainly help. The problems with national targets is that they focus on too narrow a range of services and as a result other services deteriorate.

Some years ago a Hearing Service in a hospital with which I had contact operated in the following way.
Wait 2 years to be seen by the department.
Having been seen, wait 6 months for your hearing aid to arrive.
Then discover that the aid supplied was several years out of date.

In fairness once it was brought to the managements attention it was quickly rectified.

And then there is joint working with Social Care, whose budgets are at best frozen and at worst falling, a state of affairs, that is all to likely in the next 2 years. But we all agree that hospital is not a good place for the elderly. At the present time it is difficult to see how care can be provided at home allowing the hospitals to provide care for those who really need their services.





Mark Newbold

Position
CEO,
Organisation
Heart of England NHS FT
Comment date
12 March 2013
Hi Simran, I think we become 'genuine' by re0aligning with our staff and creating a sense of common purpose. This won't happen overnight, and will need sustained effort and continual reinforcement. This is the core challenge in terms of creating a new culture. I happen to believe most managers do share similar values to clinical staff, but the strong target-driven culture has created a dichotomy. Collectively,we can overcome this - indeed we must if we are to progress in terms of quality improvement.

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