So how should we read the Operating Framework – as a conservative 'steady as we go' plan for the coming year, with a continuation of current targets and priorities, or as the operational launchpad for the post-Darzi era of a service that has quality as the defining principle? Clearly David Nicholson sees it as both. So how should chief executives approach this apparent dichotomy?
1. What does the Operating Framework mean for my overall approach?
Well if you've been around for most of the last eight years, you've learned the skills of surviving in an environment of high central control with tough externally imposed performance management targets enforced by a 'big stick' approach to those who failed to meet them. Taking risks and being creative and innovative was, at best, an optional extra for organisational leaders. Of course it's also true that you were managing this tough environment in a period of unprecedented financial growth.
The climate set by Darzi, and put into practice through this Operating Framework, asks you to turn these skills virtually on their head – of course you will have to hold on to the targets you have achieved (and there are already signs as the winter begins to bite that this might not be easy) – but now you are being actively encouraged to express yourself, be creative in driving for locally defined quality – oh and by the way, to achieve all that in a financial environment in which we seem to be rapidly approaching a cliff edge.
2. So how can I exploit the new opportunities?
The way you set up your organisation to be successful in one environment is unlikely to be optimum for the new environment. Can you create the space, energy and culture among your staff to create and innovate? If you can, are you confident that you can hold onto delivery without descending into a frenzy of target-setting and box-ticking? Has the control you needed created a closed system, with little devolved decision-making? If so, it's unlikely that you’re fostering a culture in which you are well-placed to seize the opportunities that are now on offer. Look in the mirror and ask yourself whether you are clearly articulating your vision for creativity and innovation and demonstrating your personal commitment to it. And what of those in your senior team, what of your board – is your vision of innovating for quality owned, shared and put into daily practice by them?
3. How do I make quality as a guiding principle a reality?
The word 'quality' can mean all things to all people. Have you clearly defined it for the services you commission or provide? Without a clear picture of what a truly high-performing service would offer in terms of patient experience, efficiency and outcomes, your teams are in the dark about what they're trying to achieve. You need to know what your staff, patients and caregivers would regard as quality in the service they receive – what do they see as adding value to the experience? Is it about safety, access, outcomes, timeliness, responsiveness, respect? Understanding and being able to express this clear vision of quality is tough. It will vary significantly from service to service even within organisations. The place to start is with meaningful conversations with your populations, patients and partners about the kind of service they need. Tapping into the knowledge of specialist groups can be hugely beneficial here. The skills of engaging, consulting and listening have not been central to delivery over recent years, but they are at the heart of driving for quality. And once you've crafted that understanding of what you’re looking for, you will need to understand how you can measure your current performance, benchmark it appropriately, create improvement aims and motivate and incentivise people towards their achievement. CQUIN is one expression of this, formalised in contracts, but you will want to create a broader range of motivations and rewards in the system you lead.
4. When's the right time for commissioners to involve the providers – and vice versa?
The early years of the reformed system have seen much polarised behaviour between commissioners and providers, dominated by win/lose discussions, mutual disrespect and lack of engagement. The agenda set out by the Operating Framework will require you to swallow your pride and find mature ways of working with your opposite partners, recognising that you are part of a system as well as having individual organisational interests. When it works well, providers and commissioners operate with a shared goal of achieving a high-quality service and a shared vision of what high quality looks like. It is clear that, over the coming years, fighting for new cash will become a fruitless exercise. Even in the coming year, the additional 0.5 per cent of tariff that commissioners can redistribute under CQUIN is a potential reward, but deliberately not hugely financially significant. The drive for quality needs to be incentivised financially, but not wholly driven by financial motivations.
5. How quickly should I act?
The journey towards the service with quality as a driving principle is clearly a long one – but all chief executives will be expected to pick up the early messages (for example on measurement) this year and to make progress. I don't think that the promise to hand back some control is empty rhetoric on the Department of Health's part, but to make it a reality both sides need to change their behaviour in the coming year, the Department needs to reassure the NHS that the plea to 'look out, not up' is backed up by a confidence in NHS leaders to take control and take action in their own way. Local leaders need to show that they are taking the opportunity to set ambitious goals for quality and efficiency in their leadership.
So for you, as a local leader, what would be a credible signal from the Department that they are keeping their side of the bargain? Those who ask for more flexibility in current targets misunderstand that these minimum standards are now permanent expectations. I think there are three important signals. We have already had the first; it is easy to underestimate the effort it must have taken from David Nicholson to resist the political pressure to add ever more targets – you should welcome this effort. Second, the centre should measure and recognise those who deliver quality with the same clarity that it recognises those who deliver targets. Third, because this new agenda is tough, they should focus the national, regional and local work on leadership development to support you in the change you and your teams need to make in your own skills and practice.