Jen Parsons, Associate Director of Strategic Transformation and Planning, shares her experience of working with health care systems to bring about service change.

The co-ordination, speed and effectiveness of our NHS in an emergency is a wonderful thing to behold. I’ve been reminded of this at seminal points in my life. None more so than the birth of my son, whose ‘dramatic’ entry into this world (as it was later described by the Paediatricians) precipitated a rapid influx of people to get him breathing. For me, the outcome (a healthy nine-pounder) was never in doubt, such was the skill and co-ordination of my NHS colleagues in that moment.

A set of well-rehearsed actions from highly skilled people who care made the single biggest difference to my life. Have you ever wondered what could be achieved at scale with the equivalent collective leadership, skill and focus to tackle the growing challenges our National Health Service faces?

A report on the NHS at 70[1] last year observed that the NHS “performs neither as well as its supporters sometimes claim nor as badly as its critics often allege”. The NHS has some significant strengths. It’s relatively efficient, and it protects individuals from the financial burden of illness. But it also has some notable weaknesses, the most fundamental being its health care outcomes:

“The UK appears to perform less well than similar countries on the overall rate at which people die when successful medical care could have saved their lives.”

In 2014 the Five Year Forward View[2] signalled a shift in narrative. It spoke of a need for the NHS to break down the barriers between organisations, providing more care locally to overcome the challenges of an ageing population with more complex health problems. A King’s Fund report later concluded that collaboration through place-based systems of care offered the NHS’s best opportunity to improve the health of our population. Fast-forward to 2019 and my inbox serves up constant reminders of the fragility of NHS services, of unsustainable pressure on A&E departments, and workforce shortages. Sadly, the NHS Long Term Plan was notable for the lack of anything of substance in this regard. These are not straightforward problems to solve.

At the NHS Transformation Unit, we’ve been helping health care systems plan and implement service changes where collaboration can deliver safe, sustainable and reliable services for patients. With more than a decade of rolling our sleeves up, we’ve experienced the tough lessons and understand what it takes to broker changes to a health service that belongs to everyone. We’ve translated our learning into a System Readiness Assessment, a short, focused piece of work designed to surface the likely challenges at the start of the journey. This helps our clients to prioritise resource and shape an appropriate programme of work. So, what are the common themes?

The technical requirements are the “easy” bit

Most requests for support we receive focus only on the technical work and when it can be done by. I wouldn’t want to understate the work required to put together a good business case for discussion with stakeholders and the public. But I’ve witnessed many consigned to the top shelf because the right people weren’t involved in developing it, because the process of service change in the NHS had not been understood, or because the political groundwork had not been laid and so on. In my experience it’s these other factors that constitute the real work of making changes happen, and often they’re not given the attention they require.

Afford the space and time for the real conversation

I’ve worked with systems that appear to have the right structures in place to bring leaders together. But then I’ve attended meetings and workshops where the important subjects are on the agenda, but discussion gets stuck or fails to grip the heart of an issue. Elephants are left in the room. There comes a point when a large investment of time and money risks being misdirected without a level of honest conversation that seeks a common understanding between leaders from the start. It takes a level of trust, leadership and a receptive environment to tactfully call this out and change the dialogue.

Support for leaders is often overlooked

We provide support to help systems develop sustainable models of care; business cases; and provide the underpinning modelling etc. but only system leaders (executive and clinical) can own the change and front it with colleagues, stakeholders and the public. This takes a significant investment of time, personal and professional commitment, and is far from an easy journey. I’ve found that where the need for this collective investment in leadership is recognised and prioritised, the odds of success are far greater.

Surface funding challenges early

Major service change in the NHS often requires a level of investment, particularly capital, which is increasingly difficult to come by. Financial constraints on trusts, particularly those in deficit, can also restrict an ability to act collaboratively. The King’s Fund recommend[3] that systems develop a sustainable financial model to reduce the possibility of conflict in how resources are used and distributed. We’ve also spent time grappling with the alternatives. ‘Shared single service’ models of care offer partners an option to provide safe and sustainable services in collaboration, without necessarily changing the location and access for patients (a key driver of capital). Whatever the solution, it‘s far better to agree such design constraints up front than to have to row back with clinical colleagues or the public later.

Genuine involvement of the public can be pivotal

Partnership working is vital for service changes to be developed in line with NHS England guidance. But in my experience, it‘s often secondary to clinicians and managers spending months working out the right answer in a backroom first.  We’ve evolved our transformation process to put patients at the heart of redesign work. Some examples include developing patient experience standards as part of the service specification, testing models of care with patients using experience-based-design[4], and involving patients on clinical assurance panels. Bringing clinicians and patients together requires time, skill and planning, but can completely change the dynamic and outcome of the design process for the better.

For more information on our System Readiness Assessment, please contact Jen Parsons, Associate Director, Strategic Transformation and Planning, e: jen.parsons@nhs.net

 

[1] M. Dayan, D. Ward, T. Gardner, E. Kelly, 25/06/2018, The NHS at 70: How good is the NHS? ISBN: 9781 915953 501

[2] NHS England, October 2014, Five Year Forward View, https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

[3] The King’s Fund, Ten design principles for place-based systems of care, accessed on 22/05/19 at https://www.kingsfund.org.uk/publications/place-based-systems-care/ten-design-principles

[4] See NHS England Toolkit: https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/Experience-Based-Design-Guide-and-Toolkit.pdf