In the lecture she gave on receiving the Nobel Prize in 2009, Elinor Ostrom argued that research over several decades showed that ‘a core goal of public policy should be to facilitate the development of institutions that bring out the best in humans’. Her views were shaped by her study of real-world examples of how communities avoid overuse of common resources such as forests and fisheries by collaborating rather than relying on private ownership or regulation by the state.
Ostrom’s words should be heeded by the government as it embarks on the next stage of NHS reform. Specifically, the aim should be to develop institutions that appeal to the intrinsic motivation of people working in public services to work together for the greater good. This means recognising alternatives to the policy instruments governments have relied on in the past and doing more to support staff and leaders to perform to the best of their abilities.
Failures in patient care that occurred at Mid Staffordshire NHS Trust, where leaders lost sight of the quality and safety of patient care, illustrate the limits of instruments such as regulation and centralised direction of the NHS. These leaders focused more on financial control and achieving foundation trust status than patient care, with tragic consequences for the people they served. A review conducted by Don Berwick at the government’s request after the Francis Inquiry into Mid Staffordshire identified a series of lessons for the NHS.
“These lessons included the need to foster a commitment to the NHS becoming a system devoted to continual learning and improvement of patient care and avoiding a culture of blame and fear. ”
These lessons included the need to foster a commitment to the NHS becoming a system devoted to continual learning and improvement of patient care and avoiding a culture of blame and fear. The Berwick review was critical of the use of government targets and warned that too much emphasis on financial performance could have adverse consequences for patients – a warning that remains relevant today. It also advocated streamlined regulation and cautioned against punishment of organisational leaders ‘for poor performance for reasons beyond their control’.
The report on health and social care leadership in 2022 by Sir Gordon Messenger and Dame Linda Pollard echoed many of these points, noting that the ‘constant demands from above, including from politicians, creates an institutional instinct… to look upwards to furnish the needs of the hierarchy rather than downwards to the needs of the service-user’. It went on to argue that ‘it is the role of the centre to demonstrate and drive the appropriate cultures and behaviours’ from the top of the NHS to avoid bullying and other toxic behaviours.
Against this backdrop, it is welcome that Wes Streeting has announced intentions to devolve responsibility for decision-making within the NHS, focus on a few priorities and targets, and reduce the size of the centre. He has also invited Gordon Messenger to help develop and attract the leadership talent needed in the NHS. If executed well, these initiatives could support staff and local leaders to lead improvements in patient care and foster innovation, provided that the centre leads by example in its relationship with NHS organisations.
Streeting has also announced plans to publish league tables of performance by NHS organisations and introduce ‘zero tolerance for failure’. These plans have been attacked by critics who have raised concerns about the wisdom of naming and shaming failing NHS organisations and the risk that doing so will perpetuate the poor behaviours described so vividly in the Messenger/Pollard report. An unintended effect could be that the reporting of performance data is gamed by local leaders to avoid public humiliation and its consequences.
League tables could be of value if they are used for improvement rather than judgement and help to stimulate curiosity among leaders about learning from their peers. To be credible, league tables must reflect the issues that matter most to patients, and interpretation of their results should recognise the different contexts in which organisations operate and the challenges they face. The transparent reporting of performance data used in tandem with devolution is an approach advocated by Michael Barber, adviser on public service reform to successive governments.
If Ostrom were alive today and advising the government, it is likely that she would emphasise the value of NHS organisations having greater self-determination with much reduced oversight and direction from the centre. Instead of a culture of compliance with targets set from above, local leaders would be motivated by cultures of commitment to improve in areas they identify as important to patients. In place of extrinsic motivators like zero tolerance of failure and public humiliation, the emphasis would be on creating institutions that work with staff and not against them.
The most advanced NHS organisations are already working in this way and showing what reform from within the NHS can deliver. Planned changes to the performance management regime need to build on these achievements and avoid a return to the transactional behaviours that worked against integration and collaboration. Bringing out the best in humans is a worthy goal that could make a real difference to how the NHS works in view of the association between staff engagement and patient experience.
“The government must calibrate its interventions to avoid making this harder to achieve at a time when the NHS remains a high priority for the public and the government is redoubling its efforts to improve public services.”
The government must calibrate its interventions to avoid making this harder to achieve at a time when the NHS remains a high priority for the public and the government is redoubling its efforts to improve public services. Holding NHS organisations to account for their performance is essential, but the way in which this is done must recognise that local leaders and staff need to be valued and supported to deliver the changes that are needed.
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