If we are to achieve a tangible difference in performance challenges, there must be less emphasis on assurance and checking and more support for innovation and improvement.
In the week before Christmas, the Times reported that the Secretary of State for Health and Social Care, Victoria Atkins, had called in leaders of NHS trusts where patients have the longest waits in ambulances before being transferred to A&E departments. According to the report, those present were told to stop ‘failing their communities’ and ‘buck up their ideas’ as the NHS enters what is traditionally its busiest time of the year.
Atkins is not the first health secretary to act this way and she is unlikely to be the last. While the impact on NHS performance of being told to do better is questionable, the impulse is understandable given the Secretary of State’s accountability for the NHS. In truth, meetings like this serve little more purpose than signaling that the politician in charge of the NHS is doing something to address the public’s concerns. A well-briefed report in a national newspaper ensured that her actions did not go unnoticed beyond Whitehall and Westminster.
More support for innovation and improvement
The question raised by this episode is: what else can be done to make a tangible difference to performance challenges wherever they may occur? The limits of seeking to micromanage performance and to urge staff to work harder have been in plain sight for some time. There needs to be less emphasis on assurance and checking and more support for leaders and staff to innovate and improve.
A good place to start is to use all available expertise, for example through well-performing organisations and teams supporting those with the greatest challenges. This is already happening in some areas through the work of integrated care systems, provider collaboratives and hospital groups. Slowly but surely, collaboration is taking the place of competition as the animating force of the NHS.
There are parallels in the use of sector-led improvement in local government and in the experience of successful companies in which challenged business units are paired with those doing well. Organisational autonomy has put barriers in the way of the NHS doing the same but the most advanced integrated care systems are finding ways of making progress.
The focus on collective action serves as a counterweight to organisational autonomy, recognising that time and effort are needed to move beyond entrenched behaviours
An example is the West Yorkshire Association of Acute Trusts (WYAAT), which brings together six acute trusts to deliver joined-up hospital services. Progress includes the establishment of community diagnostic centres, a single pathology network, and a network of arterial and non-arterial centres.
Another example is the North East and North Cumbria integrated care system, which has established a learning and improvement community across the dispersed population it serves. An early priority was to reduce ambulance delays by pairing up areas with longer delays with areas with shorter delays, and staff shared learning by visiting and observing their peers.
A common feature of these two systems is the emphasis placed on leaders and staff taking joint responsibility for performance. They operate on the basis of understanding that those involved have both organisational and system responsibilities and improvement is best achieved by staff who are closest to where work is done. The focus on collective action serves as a counterweight to organisational autonomy, recognising that time and effort are needed to move beyond entrenched behaviours.
Capability and freedom for systems
National NHS leaders have signalled their intentions in launching NHS IMPACT with the aim of embedding learning and improvement throughout the NHS in England. NHS IMPACT will add value if it supports the work of integrated care systems, provider collaboratives and hospital groups by focusing on issues best tackled across the NHS. This includes making use of improvement networks in a small number of high priority national services.
What does this mean for the health and social care secretary? An essential insight is that the NHS is a complex adaptive system that cannot be run through a hierarchy that is often disconnected from where patients receive care. Trying to do so is understandable given the political salience of the NHS, but taking this route is a recipe for frustration and ultimately disappointment.
…the health and social care secretary should seek a judicious balance between holding NHS leaders to account and trusting them to innovate and improve with their partners
The alternative is to ensure that integrated care systems have the capabilities and freedoms to tackle performance challenges in their areas. This puts the onus on leaders in all parts of the NHS to make credible commitments to work together and with other partners to improve health and care using all the resources that exist.
Two assumptions must underpin what happens next. The first is that NHS leaders and staff have an intrinsic motivation to work to the best of their abilities for the people they serve. The second is that the health and social care secretary should seek a judicious balance between holding NHS leaders to account and trusting them to innovate and improve with their partners. Aligning behind common goals and improvement methods offers the best hope of making progress in 2024, whichever party is in power after the general election.
Building on the start made by integrated care systems by enabling their leaders to embrace partnership working and realise its benefits should be the priority. As Diane Coyle said in her recent lecture at the Health Foundation, fundamental change in the culture and hierarchies of the NHS is overdue based on a requirement of ‘devolving decision-making to workers on the shop floor’. As a system leader put it to me, more pithily: ‘Trust us to get on with the work’.
Professor Sir Chris Ham is co-chair of the NHS Assembly, emeritus professor of health policy and management at the University of Birmingham, and senior visiting fellow at The King’s Fund. You can follow him on X (formerly Twitter) @profchrisham.