Real trust rather than regulated trust should be the foundation on which improvement in the NHS is built

Last week we launched a report setting out the case for the NHS in England to adopt a quality improvement strategy.

This case received strong endorsement from Don Berwick and Maxine Power, looking from different ends of the quality improvement telescope, and from the leaders who attended the launch event. The sense that now is the time to rediscover the importance of quality improvement was palpable with a feeling of urgency about translating the principles in our report into practice.

In his contribution to the launch, Ed Smith, chair of NHS Improvement, railed against the ‘firing squads’ that sack chief executives and chairs when things go wrong. He was also critical of the focus on short-term targets rather than long- term improvements in care. He urged national leaders and NHS boards to lead work on improvement and to see money and quality as two sides of the same coin. His message that national bodies need to work quite differently could not have been clearer.

In making these comments, Smith referred to a paper he wrote with Richard Reeves in 2006 to remind his audience of the pernicious impact of excessive regulation. In their paper, Smith and Reeves contrast ‘regulated trust’ with ‘real trust’ which is based on a belief that people have a strong intrinsic motivation to perform to the best of their abilities. They argue that real trust is not fostered through reliance on rules but rather through the development of positive organisational cultures that encourage risk taking and avoid blame.

These cultures support people to act in a way that is trustworthy and to do the right thing. They encourage ‘behaviours and instincts’ that enable people to behave with integrity at all times. Positive cultures take time to develop and require sustained effort by leaders and followers at all levels. Rules and regulations designed to increase trust all too often have the opposite effect, resulting in over reliance on compliance rather than the nurturing of commitment. Real trust cannot be mandated and emerges through the actions of leaders who create the conditions in which people are supported to be effective.

Smith’s comments offer the clearest signal yet of the beliefs of the new leadership of NHS Improvement. They echo remarks by its chief executive, Jim Mackey, that more needs to be done to support providers in difficulty, and that NHS organisations need to collaborate in tackling the growing financial and service pressures that they are faced with. But will Smith and Mackey be allowed to follow through on their commitments with anxiety levels in government about NHS performance rising rapidly?

In the short term at least, central grip on the NHS is being tightened and regulation of providers is being strengthened. The freedoms of foundation trusts have been eroded and detailed guidance has been given to the NHS, from organisations including NHS Improvement, on the actions needed to improve financial performance by the end of this financial year. The behaviours of NHS Improvement’s own staff reflect the priority attached to regulation and are often at odds with the values Smith was espousing.

There is also no slowing down in departures of leaders from trusts in difficulty and there is increasing evidence of challenges in finding experienced people to replace them. All the more important therefore that priority is given to leadership development across the NHS, another of the priorities identified by Ed Smith in last week’s speech. It is here that NHS Improvement, working with other national bodies, could make a real difference by putting in place a national leadership development strategy. This means aligning the work of the NHS Leadership Academy with work on quality improvement and supporting every NHS organisation to play its part in talent management and developing a pipeline of leaders for the future.

Our work at the Fund has shown the value of leadership development occurring ‘in place’ through coaching and mentoring as well as providing opportunities for people to attend leadership development programmes. Organisational leaders have a key role in developing cultures that value ‘real trust’ as well as in working with their peers to put in place the system leadership that is needed to develop new care models and sustainability and transformation plans. We will play our part in working with national bodies in addressing these challenges as well as supporting NHS organisations in building the leadership and cultures on which high performance is based, including at our forthcoming leadership summit in May.