The new chief executive of NHS Improvement has a daunting task. They will be taking on a new role at a time when the finances of the provider sector are already in deep trouble. The Government and regulators have resorted to a range of measures to ‘improve’ NHS performance in this challenging context: letters telling providers to get a grip; tough talk on targets; headline grabbing rows with the medical profession. These seem to suggest growing concern and uncertainty.
A leader stepping into such a demanding position might expect clarity about the purpose of the organisation, about the mandate that it has, and that there are well-understood relationships with external stakeholders. In this case, there is an urgent need to sort out these basics and get alignment between all the different NHS system leadership bodies, as well as successfully bringing together two different cultures. This has to be done at the same time as working out the long-term direction, where to focus and how change will be brought about.
To win credibility within the NHS and Whitehall, the immediate task for the new chief executive will be to gain control of the financial situation and establish discipline. This will require the ability to distinguish between the different reasons for organisations being in
financial deficit – are there issues inside the organisation that need addressing, problems in the local health and social care economy or fundamental questions about the sustainability and viability of the whole system?
The NHS has not been very good at making this distinction to date, and it is far too early to judge the efficacy of the new success regime. But the response to provider problems needs to be based on such a diagnosis, to avoid the moral hazard and unfairness that can arise when those who are making progress or controlling finance feel that the system is subsidising failure elsewhere.
To a great extent the longer-term direction has been agreed by leaders in the NHS and Government, who have endorsed the Five Year Forward View, the efficiency targets it contains, and the assumptions it makes about reducing demand and new models of care. There are also associated policies such as seven-day services, the new cancer strategy and, no doubt, more ideas still in train – few with identified funding.
The question left unanswered is how these changes are to be brought into effect. Almost every tool in the policy-maker’s box has been used, refined and found to be wanting. Exhortation and threats have also been exhausted. With over 10 per cent of chief executive posts vacant and the majority of providers in deficit, the reality is that the usual sanctions will not be effective. This is now a system-wide problem affecting the significant majority of providers. And despite the good early progress of the Vanguard programme, it is unlikely that the Vanguards will develop models at sufficient speed, scale and success that can be replicated to make the required difference across the system within the lifetime of this Parliament. Their success will be realised in five to ten years, not three to five.
The absence of system leadership locally is a major issue. Regional tiers had some benefits in providing this leadership and there is a strong argument that the system now needs some form of ‘referee’ to unblock and enable where local participants cannot agree or make sufficient progress on their own. But a repeating problem is that past incarnations of these regional tiers have encouraged a belief in those who work in them that they can be helpful, or that because they appear to be above trust chief executives, they should tell them what to do. And of course, there are developments in terms of devolution which may or may not provide system leadership – these developments will present an interesting dynamic in the relationship with NHS Improvement’s leadership.
So, instead of trying for one last push as a heroic individual or returning to the bad old days of over-dominant strategic health authorities, the new chief executive must lead in a different way. Up until now, the behaviour of NHS regulators and governing bodies has seemed to reflect a certain underlying theory: that the way to improve performance is to directly tell people to make change happen, without specifying how it can be done, and then check up
on whether they have done it. If change isn’t happening, then the recipe is usually to squeeze harder and hope this will have the desired effect. This is an ineffective method for achieving change. The temptation and pressure to grip harder will need to be resisted.
Improvement at the level that is needed can only be achieved by creating a large-scale leadership community which spans individual organisational boundaries and has shared values, aims and ways of behaving; a partnership which covers the entire service – commissioners and providers as well as local and national leaders. It must bring clinicians in to share these aims and values – no successful change can take place without them, yet disengagement is a growing danger. It also needs a clear methodology that can be replicated at the local system level and right down to the clinical front line.
It will be the role of these leaders to deliver a large range of changes, from the transactional improvements in the Carter review to more fundamental changes such as those in the Five Year Forward View. They will also need to hold each other rigorously to account for both the changes and the new ways of behaving required. This community will only work if it is based on the principles of collaboration and partnership, not command and control. This will require urgent steps to align the multiple layers of regulation and to control the epidemic of assurance, which creates distraction and unhelpfully mixed messages.
There is, of course, a whole range of technical issues to be sorted out, including the system rules and architecture that are necessary to facilitate the change. These are well understood even if, as in the case of the unhelpful competition rules or the inappropriate failure regime, the answers are not.
One important lesson is the danger of being sucked into the Whitehall machine and losing focus on the front line. Successful trust chief executives seem to have the ability to create their own narrative instead of simply being the transmission mechanism for the centre. This is difficult at trust level, and doubly so for a national role with weekly conversations on the sofa at Richmond House. Being on speed dial from No. 11 or the Secretary of State is seductive, but hazardous.
Convincing and reassuring central leaders will, no doubt, help bring the new NHS Improvement chief executive closer to meeting their elusive but crucial goals. But, in the end, he or she must remain focused on the managers and professionals who have the power to actually deliver change. As the first contributor in this collection of essays puts it, “we need to be inspired…we are…1.3 million people, not a series of systems and processes”.