Mobilising change in the NHS

Penny Pereira 

Hello and welcome back to the leading improvement in health and care podcast.

Matthew Taylor

This is the first episode of our second series. We're going to be exploring how to mobilise change and doing that particularly in the context of the ten-year plan for the NHS that we're expecting, I don't know, late June, early July. Now, the impact of that plan will of course depend on how well it is implemented. Great ideas are cheap. Changing things is much harder.

And we know that previous reforms haven't always delivered in practice and that the scale of ambition for transforming healthcare means that we are going to have to do things very differently. So when the ten-year plan lands, what will that mean for the changes you need to deliver locally? What approaches to change are most likely to be effective?

Penny Pereira

This episode brings you what I hope you've come to value from this podcast and from the work we do as organisations. We're to be looking nationally across the UK, connecting that to the practical experience from implementing improvement at the point of delivery. And our contributors today are a really great example of that. So combining experience at a system and national level with delivering change at the frontline. 

We're going to hear first from Dr Gary Howsam, who is chief clinical improvement officer for NHS Cambridgeshire and Peterborough ICB.

Gary Howsam 

We were faced with number of challenges that other practices are facing and increasing demand for our services and everyone focusing on access and how could we get more appointments, how could we see more people, how could we really just do more without any additional resources in terms of finance or staff. 

So back in 2023 we had some facilitated support from an external quality improvement team that was part of the modernising general practice programme, and the general practice improvement programme in particular. And that was over a period of nine months. They came in on a weekly basis. We had a GP partner, our operational team, so that's our business partner, our operational lead and our practice manager. So a morning a week with the facilitator and then a lot of homework in between times. And two years later, it's absolutely transformed the way that we work the practice.

It was transformation by stealth, I think was the first thing that we learnt, but it did involve the whole of the team. And I think the other important thing we learnt is that every time we made an improvement, it just threw up another problem. So the successes were very short-lived because then we moved on to the next piece of work we were doing. We involved our patient participation group. We involved all the members of our team. And I say that the learning from that has not just helped me in that role at the practice, but also when I'm trying to facilitate change at an ICS level. 

So I think the big takeaway for me from that was that improvement work is continuous. There's never just one thing to improve. And once you think you've got there, you can see opportunities for further improvement. It's harder than we thought it was going to be. It took longer in terms of the time to generate the change. And it was more costly, both in terms of human resources, time commitment, but also emotional commitment.

And I think the recognition that it impacted all 60 people that work in the team. There was nobody whose role wasn't changed or impacted by the changes. So it's really important that we communicated all of that and moved at the speed of trust of the person that took the longest to get on board with it. Because if we left people behind, we knew that the change was likely to fail and be more easily reversed.

So getting everybody on board with potential for change in their roles was key. 

The other thing we learned and I'd share is that it's really important to share the successes, but it's really important to assess really quickly when you're failing. Some of our change ideas were really bad in hindsight, but it was recognising that we were having a bad idea and we tried to implement it was key to us moving forwards and not blaming people when things didn't work. We'd sat down, we'd planned a change, we'd instigated a change, and if it didn't work, that wasn't anybody's fault. It just wasn't the right change to have made and allowing us to iterate and move forwards again. 

Consulting with our patient group was really powerful as well. It's really important we had those on board when we were trying to lay out the scope of the problem because asking them what the problem was using our service was perhaps different to the problem we'd have landed on and tried to fix if we hadn't have spoken to them beforehand. 

So really spending the time to scope what you're going to do before you make that shift because otherwise you jump to fixing the problem without really knowing what the problem is that you're trying to nail an improvement in. 

And then I think the other thing we learned quite quickly was that, this was done over a two year period, and change fatigue is real. Some people that were championing it at the start got fatigued and needed a bit of time to step back. And those that were perhaps a bit reticent to step forward at the start were really infused by the changes that they could see happening. So we had different people championing the change at different stages. And that meant the energy from the team allowed us to carry that throughout the process.

Matthew Taylor

Well, it's great to hear there from Gary what's needed in terms of change and involving people in that. It's interesting around the ten-year plan process, Penny, that in the early days there was a really comprehensive approach to engagement of public, patients, staff, all those kind of working groups. But now it's kind of coalesced into a much smaller group of people who were working on it in detail. It's really important that that link is retained between that engagement process and what finally comes out of it. 

Now, our second contributor is also going to start with this question of the kind of key conditions for change. Annie Williamson is a Research Fellow in health and care at the Institute for Public Policy Research. The IPPI – I used to run it a long time ago. Anyway, but she's also a practicing doctor in the NHS with direct hands-on experience of leading improvement works. 

So who better than Annie to give us a perspective on involving staff in change, the challenges and also examples of where it's done well.

Annie Williamson

Across the NHS and across England, we see huge variation in engagement and in staff morale at the moment. So there are bright spots across the NHS, but there's also a significant middle band and areas falling behind where we just are not seeing the setup for people to engage and to bring their best. 

So to take one example, at a trust I was hearing about recently, these surgical nurses had their rota redrafted effectively overnight. No consultation, no discussion, a shift on when they had to do night shifts, how many shifts per week. This clearly takes power over one of the most fundamental things in people's lives, when they're working, when they can rest, when they can be with family and commit to other priorities, out of people's hands in the name of improving efficiency for patients. But totally disregarding the human kind of input that's so fundamental to good care. If the staff feel disempowered, then they're not going to be able to work at their best for patients. The whole thing falls apart. 

On the other hand, in Brighton and Sussex, we see a staff-led new rota to assign staff across A &E. They built in learning approaches, they built in AI. And now this rota can help people assigned to shifts swap shifts between themselves more effectively, their staffing ratios have gone up, their retention of staff has gone up. This really works because staff were involved in leading the improvement rather than having it done to them. 

Overall, the picture is concerning in terms of autonomy right now. Another point I'd bring in in terms of the current status quo is the green shoots we're seeing at the kind of cusp of the ten-year plan. 

So NHS staff retention has shown some significant improvement over the last year or two. That means people are more willing to stay, keen to stay and potentially motivated about what's to come. 

And we see the organisations that are meaningfully listening are getting amazing results. So East London Foundation Trust is a great example of this. They've had over ten years of really embedding improvement in everything they do from the board level where staff will present initiatives and programmes they've been leading, right through to how there's engagement with local community organisations. There's a lot of assessment of what's being tried and then reworking and continuing to improve. 

And that trust has gone to outstanding and continues to have outstanding ratings on the CQC multiple years in a row. They've been one of the top performers in that area and the staff and patient feedback is really positive. So we see that this improvement approach delivers the outcomes that we all care about.

Matthew Taylor

So that's fascinating, I think, Penny. It's great, isn't it, to hear from Annie giving us an example of where things didn't work, how not to do it, as well as how to do it. I sometimes think that we are better at talking about what works than really understanding what doesn't.

Penny Pereira 

Yes, indeed. And we often get quite focused on the big ambitions for what we hope will be possible in relation to change. And I think that'll be particularly true as we're setting some big ambitions around the ten-year plan. But it's easy to forget all of the pitfalls along the way. It's easy to forget that actually you need to get into the granular detail of perhaps like dozens of different interconnected processes behind any one line that's in a board paper or in the ten-year plan, for example. 

So when our examples of improvement that's gone well or when our ambitions about change are summarised, then often it gets distilled to a few inspiring sentences. But I think what I really took from Gary and Annie is actually the granular detail, the iterative approach that's needed. If you're going to actually make services reliably better and you're going to take staff with you. I thought they brought forward really powerfully how actually, if it's your staff rota, if it's your practice and day-to-day work, actually, you're going to have a real interest in making sure that any change is thoughtfully done. And if that doesn't happen, we should expect that those changes will be unpicked.

Matthew Taylor

And there are some kind of recurrent themes, aren't there? There's the importance of time, that these are iterative processes that they go through ups and downs; the importance of engaging all the partners in that work, that even if only a small number of people don't kind of get it, aren't part of it, it's going to slow you down an awful lot. So it's really worth spending the time getting that buy-in. But also the importance of having, looking at all elements of this, you know, it needs to work for clinicians, it needs to work for the non-clinicians, it needs to have a strong financial operational case underpinning it. 

That all of those things are really, you know, they are key ingredients aren't they Penny? I always think that kind of improvement, it is a bit like cooking a meal that there are maybe some dominant ingredients, but actually there are others that you might not first think of, but if you don't include them, it's really not going to taste as good.

Penny Pereira 

And that's why actually taking the iterative get on and try it approach is much more likely to be successful in the long term, rather than try and work everything out on a in theory in advance and everybody argues over what the perfect model is. Actually, if you kind of get in there and start trying, you soon discover the few things that you've forgotten that actually end up being much more critical than you'd anticipated.

Matthew Taylor

Yeah, and that's something I think we'll come to a bit later in our conversation Penny, when we talk about the ten-year plan is also listening to Annie and Gary. It does underline how very different the kind of process of policymaking in government, the political process of policymaking is from the iterative process of improvement on the ground. These are two very different domains. 

I'm reminded, I think, of that Mario Cuomo quote, which is, we campaign in poetry and we govern in prose.

Penny Pereira 

I think this is a really important lesson for leaders who are wanting to sponsor, encourage this kind of work in their organisations. Because actually, if you set too firm a specific goal upfront, if you try and drive the ambition of work in a way that, you know, I'm sure people intend to signal its importance, actually that can close down the spaces for people to fail, to say, actually, we thought this was what's going to work, but we need to adjust and we need to change again.

So there's a really difficult balance to be struck for leaders, a different kind of leadership that needs to accompany the sort of continuous improvement work that Gary and Annie talk about. 

Let's hear from Annie and Gary again. They're going to unpack now some of the underlying principles that guide this sort of work, principles that I think do pose opportunities but also challenges for those leading organisations. 

We're going to hear from Annie first this time.

Annie Williamson

The best improvement theory, evidence, case studies I've seen follow a number of steps. They use measurement and metrics, but they use that as motivation, not just as assessment after the case. 

So if you're implementing an improvement project, whether it's trying to streamline through gallbladder surgeries more quickly so more patients can get care or collaborating better with people who are at risk of developing tuberculosis in sort of dense living environments. We need to measure from the outset. We need to set the terms. What are the two or three measures that will really determine whether this is working and set those goals jointly with the frontline staff delivering the care and with the patients and communities we're trying to serve. Have those clear and measure them in as close to real time as possible - one month in, six months in, we're testing, are we working against that and how do we refine if not? Rather than three years later looking back saying, we succeeded or we didn't, park that, let's move on. It's a different approach to measurement and I think it helps accelerate change in that ongoing learning process approach rather than simply getting a nice abstract published but not taking seriously that we can make things better going forward. 

Beyond measurement, the goal of accelerating change should be improving services rather than perfect services on day one. And that links to the measurement approach. I think it's a useful mindset because in a way it takes the pressure off. If we try to set up a perfect programme for people who have heart disease and kidney disease and diabetes all at once, say, really quite complex when you're struggling tobring together services that have always worked in silos to support patients who have all their conditions at once and don't have those split up. 

It is difficult to picture what a perfect system would look like right now. But if we let the perfect be the enemy of the good, we'll be far from that improvement methodology and from the best of improvement kind of evidence that we can learn from. 

Instead, at a certain point, we need to start. We need to have the seed funding or the frontline-led efforts that get going and then quickly measure and are empowered to make tweaks to improve over time. 

So that's something we're drawing on the best of Q community, of learning from peers, on sort of standing on the shoulders of giants, but also setting people up to continually assess and improve with the right training, with the right leadership is really important. 

Thirdly then, how do we spread change? It needs to be as deliberate as the change itself. So that means having a plan to share what works, to share best practice.

I've seen this done really well. Up in Greater Manchester ICB, they have a dashboard that pulls together live patient data and population health data across the ten councils that are part of that combined integrated care system. That means what's working in one area can be communicated directly to another council with quite similar demographics. Across the NHS, we can also set up those sort of learning networks. So rather than saying, there's a great idea in one corner of the country, everyone learned from it, or imposing it on others, you can use data and link up trusts, organisations, ICSs that share characteristics and set up that dialogue in a learning network without imposing on anyone.

Matthew Taylor

That was fascinating, really interesting the emphasis that Annie puts on data, information, knowledge. These are very, very important parts of this process. And that's a whole range of things she ends up talking about the data system in Manchester, but she also talks about best practice. And these are important parts of our toolkit here. 

Let's now go back to Gary, who's going to echo, think, Annie's comments on iterative change, but also stressing the importance of peer-led improvement and doing that at a place or a system of going beyond the boundaries of the organisation.

Gary Howsam 

I think it's important we look at how we deliver capabilities, how we create leadership bandwidth. That's especially true for independent contractors across the primary care disciplines. They don't have time to design change. They don't have the time to deliver change that perhaps dedicated teams within other sectors would. And I think that's the other reason it's really important that we don't maintain the of siloed improvement resources that we have in organisations at the moment and that we raise those up to a system level so that clinicians and care providers across the system will be able to deliver that. 

I think the other thing that's important in terms of the role of the ICB is we've already acknowledged that lasting change is going to be led from the front line. The front line understand the realities of care delivery and are best placed to identify solutions, but they often need air cover and they need barriers removed, be that operational, bureaucratic or cultural that slows their progress down. And the role of people in jobs like mine at ICB level is going to be championing that learning culture over a blame culture and really getting people to understand that continuous improvement is all about the collective effort that people make together and not about individual risk, which is why I think sometimes programmes don't move as quickly as they would do otherwise. 

And I think peer led change are often more effective as they can address the concerns of other clinicians, often around different variations in risk and how risk is going to be held by people working on the front line. 

I think the other value of the clinical leadership is that it can span organisations and promote cross-system working, which again is going to be absolutely key to lift this improvement work out of the silos of organisations where it's historically sat and get it moving at a system level.

We did a bit of work around an urgent and emergency care hub, which was bringing together a number of different services across primary care, the ambulance service, our local authorities, rapid response services, our community providers rapid response services and also call before convey and our emergency departments, all with the aim of reducing the number of people that landed inappropriately at the emergency department when they could have their needs best met by a community service or by just giving them access to information and options prior to them landing at the acute site. 

And the exciting thing about that programme is the person that led it, she took a very explicit, we're going to do this through a continuous improvement approach. We are going to measure where we're starting. We are going to look at the options. We are going to speak to the people using the services. I want to know how this is going to impact the people that deliver the care. And because that continuous improvement was called out in such an obvious way, I think it helped people get into that mindset of iterative change.

Penny Pereira 

Yeah, so Matthew, I found that a fascinating set of perspectives from Gary and Annie. I guess you spend a lot of time promoting the importance of system working, of transformation work across systems. How do you help people make the financial, strategic case for taking a system improvement approach that has that iterative approach that is necessary when you're dealing with complex systems?

Matthew Taylor

Yeah, that's right, Penny, but I'll start in a position which you might find surprising. You might tell me it's just wrong, but I kind of think you have to start from recognising and acknowledging how difficult it is. That actually I run an organisation, you run part of an organisation, you run a network, it's much, much easier to drive change in organisations or bits of organisations that we run than it is to drive change in working with other people. And that's particularly the case when everybody's under a lot of pressure. 

One of the mistakes I think we make is that we underestimate how difficult that is. And then we underestimate therefore the amount of time that has to be spent building a sense of shared purpose, the kind of soft end of this shared purpose and trust. And then the hard end of this, which is shared data, thinking about things like incentives and financial flows and all of that that you need to get in place if you really want to do things differently. 

Yet often when we talk about system change and collaboration, what we're saying to people is we're asking you, particularly in the short term, to do really generous and trusting things with people. It's hard to do that if you haven't really built relationships and a very strong sense of common purpose.

Maybe, given how difficult everything is, it's paradoxical to start off by saying you need to recognise how hard it's going to be, but I think if you don't, you're not likely to get there in the end.

Penny Pereira 

I think that's so important and actually the principle of authenticity in those relationships, in the way that we talk about change is absolutely critical and is going to be cornerstone to what's going to need to come out at the point at which the ten-year plan is published and then what follows from that. 

So we need to acknowledge that this process is going to take time, it's going to be hard work and we also, I think, could benefit from a much more explicit conversation about actually how the finances and what's possible in terms of quality are interconnected, how the choices we're going to need to make will often be hard, but that actually if we show that those harder choices should be driven more clearly by shared data alongside the trusting relationships that allows you to collectively make sense of that and actually move to action together.

Matthew Taylor

Which brings us, think, doesn't it, back to the ten-year plan, because the ten-year plan is not going to be iterative in the sense that it'll be published and there'll be a lot of publicity and it'll be advertised as a kind of new start for the NHS. 

But its authors need to understand in the end, the people who've got to deliver this on the ground have got to have the capacity to do the kind of iterative work that Gary and Annie have talked about, that kind of measuring and learning and iterating. There's got to be the kind of flexibility. Yes, broad principles. Yes, there are some big things that need to be changed. Yes, some clear prioritisation. But there's got to be room for that kind of iterative experimentation and learning to take place on the ground. 

I think it's kind of interesting, Penny, that the last bit of our conversations with Gary and Annie focused on what they felt was really important in terms of the ten-year plan making the difference that we know the Secretary of State and other people in the Department want to achieve. 

So let's hear Gary's thoughts first.

Gary Howsam 

I think with the ten-year plan, I swing between being very, very excited and totally terrified by the quantum of change that may well be necessary on the back of it. 

I think if you simplify it down, they're asking us to do two things: improved the long-term health outcomes of the population and ensure the sustainability of the NHS. 

Now, they are both big things to be aiming for. And I think the three shifts to prevention, to community-based care and to digitally enabling the service are going to be key as we respond to the change in our population and the change in our population's needs. 

And I was really excited at the start when they said, look, when you're considering these changes, let's talk about paradigm shifts, let's go beyond conventional policy thinking, you know, be bold and brave and radical in terms of reforming ways of working. And that's a really exciting sort of thought space to be in when you're addressing problems, because I'm a big believer in getting people together to properly explore the art of the possible and not constrain the thinking by the current challenges that we might be facing. 

So if the quantum of change is going to be as big as the plan aspires to, then the way we go about mobilising change is going to have to be of a different quantum as well. And I think we need to shift away from sort of the traditional top-down sort of directives that are very common in the NHS to actually finding a way of not only engaging and reconnecting the population with the NHS, but really putting them at the heart of the changes. And for me, really empowering the frontline, they're going to be the agents of change. 

And the other thing that I think is important is going to be getting some momentum behind the change. If this really is going to be a ten-year plan, then that gives us a timeline to deliver big changes, but I think to get people on boarded at the start to get people infused by the change, we need to see some change now. And that quantum of change at the start is as important as the quantum of change over the decade of the plan's duration.

Annie Williamson

I'd say the ten-year plan overall and any ambitious desire to transform a health system carries key obstacles. They're the flip side of that ambition. If you're setting out a genuine vision for change, there's a delivery risk that you fall short. So specifically, three challenges that warrant careful consideration in advance.

The first big challenge, the day one challenge when this plan is announced is establishing credibility and buy-in from the outset. So that's credibility with staff, with patients and with the public. This plan needs to feel different, not just different in terms of the words that are used, but in terms of how tangible and how grounded in potential to deliver it feels. So the process has shown promise level of engagement is different to what we've seen before. But day one, if this feels like it has the potential to change things, you already unlock that sort of latent goodwill and latent set of ideas from staff, from patients that's resting there. If that opportunity is missed, it will be quite challenging to rebuild over time. 

The second obstacle or challenge I'd say is that the reform approaches are not quite settled. And as we talked about earlier, the power of reform is just as important as the what, so we need to reach for the right levers to get there. Now there's significant delivery risks otherwise. The government have set out the ambition of their goal, but if the levers they use are going back to the old toolkit of top-down targets, of sort of narrow ideas of competition and regulation, rather than looking at the best evidence, turning to improvement methodologies, patient activation and empowerment and genuine devolution and autonomy, then we can't expect new results from old tools. And so there's a risk that we set a new vision without learning from the best way to get there. I think that risk can absolutely be guarded against through a real evidence-led approach, but that is critical at this stage. 

And then the third challenge I would say is there's a temptation to strive for flagship commitments or commissioning announcements but underplay resourcing change. And we've talked through this about how you set up for effective improvement. It is critical to have the time, to have the funding, to have the longevity that backs improvement over the long term. If we don't do that, or if we pivot all those resources towards new announcements for conditions, but not the underlying kind of fertile ground to get there, then again, we'll fall short.

And part of this is improvement and investment in staff and in patient pathways. Part of it is also about institutions, the sort of mechanics. So particularly at the moment, we need to beware any temptation to cut and slash ICS budgets, where we've seen that there's been kind of pullbacks there or cutbacks to ICSs lead to the sort of patient engagement and the population health functions being pulled back just at the time we need them most. 

So rather than looking for quick savings on the institutions, it's about viewing that as an investment in the future potential of the system to unlock great health and therefore to unlock great prosperity, economic growth, all the other outcomes that are secondary to health but actually really important when we think about the flow throughs. Of course, most of all, it's about setting up the foundations for the ten-year plan to deliver a healthier, better society for us all.

Penny Pereira 

Annie Williamson, there's some really great reflections. I think about what Gary was saying about swinging between feeling excited and terrified by the quantum of change that's going to be needed to implement the ten-year plan. I just wondered how you were feeling about it, Matthew.

Matthew Taylor

Yeah, look, it's clearly in a challenging stage at the moment. You know, there is a ten-year plan draft out there that some people have seen on the people are going to see it. Bits of it, I think, have been kind of farmed out to people to work on in depth. But, you know, this is the nature of these kinds of things. As I think Annie said earlier, you know, we mustn't make the best the enemy of the good. We need the plan to help us drive change. It's not going to be perfect. It's not going to cover every base. And of course, it's not as if policy is stopping while the ten-year plan process takes place. And that will be the same afterwards. The ten-year plan will be published, that'll be a new start. But then a week later, two weeks later, all sorts of other things will be published. So that's the kind of nature of things. 

So you've got that happening. And then also there's the relationship with the comprehensive spending review. Because a big issue for any plan is, well, how much money can we spend on this plan? And whilst I don't think the ten-year plan will be able to answer that question for more than the next two or three years, and we all know there won't be very much money. The negotiation with the Treasury, convincing the Treasury that this ten-year plan can deliver things they care about, like improved productivity, well, that conversation's only just started, as I understand it.

Penny Pereira 

I mean, you describe vividly the challenges with getting to the point of having a plan that people will agree to publish. But I guess the same things will be true and doubly more so when we actually come to trying to implement the plan, so thinking about the transformation ahead for like every organisation, every team, every system, trying to integrate the significant focus on transformation, that becoming much more mainstream business but recognising it will always coexist with the ongoing responsibility to deliver services and managing the kind of next and other disparate policy and other things that are coming your way. 

It makes me think that our approach to actually mobilising change likewise will need to be much more sophisticated in terms of bringing together different sorts of strategies for change. 

So sometimes when people talk about mobilising change, they think of the work to inspire people, to help connect them to the vision as to why they get up in the morning. But we can't only do that if we don't then also have really effective programmes that allow us to move quickly to show traction on some of the key commitments. 

But then that in itself isn't enough. If we think about the ten-year plan as being about a series of programmes, we're going to be falling well short of actually the shift in how organisations need to operate day to day that is really going to be necessary if we're actually going to transform in a way that is financially sustainable longer term.

Matthew Taylor

So thanks again to our guest, Dr Gary Howsam, who's chief clinical improvement officer for NHS Cambridge and Peterborough ICB and Annie Williamson, Research Fellow in health and care at the IPPR. 

Now Penny, I'm going to spring this on you, but it just occurred to me that we have this phrase, we, a penny for your thoughts. So I think we should end every episode in this second series with ‘a thought from our Penny’. One thought that of all the things that you've heard in this episode, the one thing you want people to walk away from this episode thinking about. So go on, a thought from Penny.

Penny Pereira 

I'm not sure about the cheesy set up but very willing to rise to the challenge. I think what this has crystallised for me is that effectively engaging staff, equipping them to lead the change, that's what's going to make or break the ten-year plan.