NHS leaders must change to make a reality of reform ‘from within’

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Last week we launched a new report analysing approaches to the reform of the NHS in England at a breakfast seminar with contributions from Stephen Dorrell, Ara Darzi and David Dalton. The report argues for there to be much less emphasis on reform driven from the top down by politicians and regulators and for much greater priority to be given to reform led from within the NHS itself.

Stephen Dorrell supported our argument that politicians should focus on setting the direction for the NHS and accounting for the use of resources – and should avoid becoming involved in operational issues. The proper role for politicians in his view is overseeing the commissioning of services, with providers having responsibility for deciding on the best way of meeting the requirements of commissioners.

Ara Darzi argued that politicians have become technocrats focusing too much on targets and not enough on mobilising commitment within the NHS. Mobilisation, motivation and capability are critical to the further reform and improvement of the NHS but in his words are just ‘not sexy in Whitehall’. He argued that reform needs to refocus on business units within the NHS instead of on the system as a whole.

David Dalton gave his perspective as chief executive of Salford Royal NHS Foundation Trust, one of the case studies in our report, where the aim was to become the safest organisation in the NHS. Key ingredients included setting specific goals for improvement and measuring progress towards them. Transparent reporting of the results helped to stimulate change as did investing in staff through training in quality improvement methods.

Dalton highlighted how his role has shifted to engaging with and supporting staff, and deferring to their expertise, rather than leading from the front. Over time this has produced positive results with Salford Royal performing well on key indicators such as mortality ratios, staff experience and patient experience to the point where it can claim with justification to be a leading example within the NHS.

The snag? The approach used at Salford Royal takes time to work in a context in which politicians and regulators are often impatient to see improvements in care. It also depends on NHS leaders being willing to move away from a pace-setting style to embrace a model of leadership in which they work with and support staff to bring about change.

The leaders of the international case studies described in our report have all shown a deep personal commitment to service improvement, including undertaking training in quality improvement methods themselves. They have also had to change their own leadership styles when they have understood that real and sustainable change relies on motivating and engaging many hundreds of staff in improvement work. The message is clear: unless NHS leaders are prepared to change, reform from within will remain a distant dream.

These insights align well with the approach we are taking within the Fund in our leadership programmes, as described in two new reports launched at our fourth annual leadership summit in May.The Fund will be playing its part by helping to develop the leaders needed to build collective capability and shape change from the bottom up instead of the top down. We will also be using the experience of high-performing organisations in our programmes to support NHS leaders learn from the very best.


Theresa Shaw

Comment date
19 June 2014
Excellent breakfast seminar, recommend listening to all the speakers - inspired my latest blog http://fons.org/common-room/blogs.aspx

david oliver

Consultant Physician,
Royal Berks
Comment date
20 June 2014
I put and FOI request into the DH from my City University email a couple of months back asking how much the NHS family was spending on management consultancy. The results were eyewatering and frankly shameful and yet i have never seen reductions in consultancy spend mentioned in major QIPP programmes. The NHS already has a huge amount of in house knowledge to share about how to drive quality improvement in services. We need to get much smarter at dissesminating and implementing "what good looks like" from the places who are delivering it already. And i suspect that people who are steeped in NHS clinical leadership or operational management and still working in the service know at least as much about how to deliver it as anyone from a a corporate consultancy. I would suggest making unjustifiable consultancy spend a "never event" enough to get a manager taken off the fit and proper persons register. And stiff financial penalties built into contracts with consultants (and especially IT consultants) for advice or systems that are flawed. There is much talk of "accountability" in the public sector currently - what's sauce for the goose....


Felicity Taylor

National Medical Director's Clinical Fellow,
NHS England
Comment date
20 June 2014
As a senior paediatric trainee and a leadership and management fellow, I am aware that each and every hospital, GP surgery and community is choc-full of untapped leadership potential: the so called "junior" doctors and nurses. Harnessing this rich and diverse resource of enthusiasm and ideas before they become disillusioned and disengaged should be a key priority for all established leaders- both to aid succession planning and to keep themselves challenged and fresh. Bring these members of the NHS community to the boardroom table and you'll be surprised at the results.

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