Transformational change in health and care: five small steps to make a big difference

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The growing demands in the health and care service reinforce the need for transformation. Much has been achieved already but more is needed, for example by focusing on staff and communities, and further understanding their lived experience. Our recent report, Transformational change in health and care,  explores the stories of 42 people involved with transformational efforts in four sites. This work shows that five small steps can make a big difference to strengthening the work of transformational change – for example, by those in sustainability and transformation partnerships (STPs), integrated care systems (ICSs), or more widely.

Reaching out

All four stories show the importance of partnership working and the great value of involving local authorities, communities, clinicians, politicians and the voluntary care sector – all of which hold invaluable insights about local needs as well as powers to help address them. Those working to integrate care should assess how well-represented these groups are in local partnerships. Colleagues from Salford emphasised the point that reaching out requires an understanding of the people you are reaching out to. For example, engagement with clinicians and communities can be considerably enhanced by changing the language used. Instead of setting out plans for integration and what changes are needed, they found that it was far more effective to seek ideas and to focus on quality and what it means for patients and staff.


It sounds simple, but a conversation with a whistle-blower recently reiterated how little we, as a system, listen, and what a detrimental impact this can have on individuals and on care quality overall. The case studies in our report show the need to proactively identify issues and work from the inside to enable solutions. This requires three things. First, as Don Berwick and Chris Ham advocate, those involved need to take a personal interest to understand situations and find out more about them. Second, Northumbria interviewees describe the need for greater self-awareness – choosing to put aside biases to hear what is being said, patiently assessing each time whether there is a need to act. Third, power dynamics need to reversed – for example, Ben Fuchs describes how 'open door' policies, even with the best intent, can be ineffective or act to reinforce top-down power dynamics unless they are coupled with open and curious mindsets and behaviours.


Open door policies, even with the best intent, can be ineffective or act to reinforce top-down power dynamics unless they are coupled with open and curious mindsets and behaviours.

Wendy Saviour, from Nottinghamshire Integrated Care System, echoed our message about the need for a more organic approach based on local needs rather than one that seeks a simple solution or a single model. Multiple interventions are likely to be needed, as is a learning approach across the system to develop, test, review and refine plans. As Wendy notes, ‘It is not the easy thing to do to work in this way, but it is the way to quality and sustainability’. This message is important for national and local efforts to reform health and care organisational structures and approaches – for example, fostering new ways of commissioning to ensure quality and partnership working. 


The stories show the need to focus on learning and to build from the rich experience that already exists rather than to keep starting afresh. The stories highlight the importance of focusing on lived experience and not just on form or models, and they can be used to aid local discussions. The research team and advisory group members have already outlined plans to do this – for example, with Shropshire and Telford and Wrekin Sustainability and Transformation Partnership, which has been awarded £300 million for emergency care transformation. The stories also highlight the need to learn from 'successes' and 'failures' and this requires the need for open cultures and freedom to both speak and learn. 

Developing positive approaches

The stories show the importance of positivity and of building on assets that already exist. For example, Birmingham shows the power of using data positively to motivate staff to improve quality rather than negatively to criticise. This is seen in our wider work as well. For example, Frimley ICS reiterates the power of clinical leadership to deliver transformations that improved quality and morale, decreased demand, and reduced staff turnover. This includes providing the time and support for people to get involved and creating structures that support rather than hinder transformational change efforts. 

Next steps

These five small steps will require an individual and collective approach to truly transform health and care. We hope that this report will spark conversation and action to strengthen the many impressive efforts already under way. For now, we're asking you to share your thinking: how will you use the report to transform health and care? What would be helpful from us and others to supplement your efforts?


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