Features: February 7th, 2014

The NHS is responding to unprecedented challenges with a transformational change programme. A survey to find out reactions to the changes and the impact they are having found that all is not well. This article identifies the main weaknesses revealed in the survey and suggests a range of responses.

They say change is the only constant, and those in the NHS are likely to agree as they find themselves nine months into the biggest transformation seen in its 65-year history. The scale and depth of these changes are such that there is much to do before the reconfigured system can operate at its optimal level.

We at Moorhouse wanted to get to the heart of how health sector leaders were dealing with this major change, so we commissioned our “Fit for the future?” report. An independent research company surveyed over 150 senior leaders in the NHS and from across the health sector, both clinicians and managers. It found that healthcare leaders have concerns about how the system is coping with the implications of the changes.

The survey findings must be put into context: it is not unexpected that stark views are expressed so soon after the conclusion of such a transition. Equally, they cannot be ignored if the system is to rapidly move towards its intended operational state.

Almost half (45 per cent) of senior health sector leaders told us that they believe there is no greater accountability for patient care as a result of the reorganisation, with only three per cent believing there is more accountability. Only four out of ten leaders (42 per cent) are optimistic about the ability of the NHS to deliver high quality and cost-effective care over the next five to ten years. And fewer than 30 per cent see that these changes have had a positive impact on their ability to achieve efficiency savings.

In addition to this, only a third (34 per cent) of leaders feel that their organisation’s new role and purpose in the system has been very well or extremely well defined. Around a quarter of health sector leaders do not see a clear vision for their organisation over the next three to five years, and only 18 per cent believe this vision has been well communicated to staff.

Addressing key challenges
However, change takes time to bed in; it is too soon to determine whether this reform will be a success. In our experience, any sector wide change on this kind of scale, and at this point following implementation, will have some areas to improve upon. Through the research findings we have identified three key challenges that organisations should seek to address in order to successfully establish their roles in the new system and help to achieve the intended outcomes of the reforms.

Challenge one: The absence of a clearly communicated vision is creating a disconnect within and between organisations across the sector.

Recommendation: Create and communicate a compelling vision for the organisation so that management, staff and external stakeholders have a clear understanding of what is expected of them.

Our research found that only 21 per cent of non-Board respondents believe that there is a clear vision in place for their organisation. Interestingly, at Board level this rose to 60 per cent, indicating an internal disconnect around clarity of vision at different levels of these organisation. Given the complexity of the changes this is not surprising but it is still needs addressing, as a lack of clarity can manifest in low employee engagement and morale. In fact, only seven per cent of non-Board respondents feel more motivated than 12 months ago.

At this time it’s particularly important for staff across the health sector to know where they are heading and understand how they personally can contribute to achieving their organisation’s objectives. Effective communication will help galvanise staff into taking personal responsibility for delivery of the strategy.

In addition to staff, the desired end state vision also needs to be communicated to partnering organisations as they grapple with uncertainty around their own roles and how to work collaboratively with others.

Challenge two: Across the sector, change is not being managed effectively, risking failure in realising the transformation’s intended benefits.

Recommendation two: Promote an understanding in the organisation of why change is required and ensure that the development of the capability to deliver is hardwired into resource planning.

Whilst the health service has already seen a lot of change, it is by no means at an end. Currently, the culture of many organisations in the health sector is not one that encourages change and may even hinder innovation. Only 15 per cent of those surveyed believed that the sector’s culture even slightly encourages change.

Accepting that what worked in the past is unlikely to work in the future is the first step in addressing competency gaps. Change needs to be embedded in the DNA of an organisation, and seen as a constant rather than something that only happens occasionally. A culture that breeds confidence and motivation to change is critical for generating the belief that the organisation can deliver its objectives and for avoiding ‘change fatigue’.

Some aspects of organisational culture will have a greater impact on the ability to deal with change than others. Leaders need to identify what aspects are a priority, and they too must buy into the culture and lead from the front. Examining how the organisation interacts with others and reacts to challenges with innovative responses is a good first step.

There also needs to be an honest appraisal of what capability is possessed, and where the gaps lie.

Challenge three: Uncertainty around how to collaborate across the sector is diminishing organisations’ ability to deliver joined up solutions to address the unprecedented challenges they face.

Recommendation three: Invest time in developing and maintaining relationships with partner organisations enabling effective joint working to address the challenges that one organisation cannot overcome alone.

The need for integration across the sector was acknowledged by survey respondents, yet a more fragmented system has caused uncertainty in how they should be collaborating. The new system is intended to ensure that well performing organisations continue to succeed, whilst those that are performing poorly may be allowed to fail, so the implications for an organisation that does not adjust to the new ways of working are serious. Fifteen per cent of providers expect there to be a reduction of 50 per cent or more in the number of commissioning organisations over the next five years and 63 per cent of commissioners feel the same.

With a clear vision and confidence in their delivery capability, organisations are more likely to be able to work together effectively and this collaborative attitude needs to lie at the heart of the future health sector.

We are already seeing examples of organisations embracing this new, collaborative way of working. NHS England, CCGs and providers are developing a five-year planning cycle that will have a more strategic forward-facing focus than the existing annual cycle. And Monitor and the NHS Trust Development Authority are working closely together on how to provide effective oversight of, and support to, the anticipated increase in changes to how providers deliver care, with the likelihood that less sustainable organisations will disappear.

The huge scale of the changes in the health sector means that there is a lot still to be done before it operates as intended. But the sooner these challenges presented by the process of transformation are resolved, the more quickly the benefits will be realised, the associated risks mitigated and the NHS set up for success in the future.

Joe McGarry is Principal at transformation consultancy Moorhouse