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This is a guest blog.
Guest authors bring different perspectives and diverse voices to our blog. They do not always represent the views of The King’s Fund.


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


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Finally, Francis has reminded us that the priorities governed by targets are now out of date.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.