Dalton review: Good leadership will determine the best models for change

The American humourist H. L. Mencken famously suggested “to every problem, there is a solution that is simple, neat and wrong”.

‘The management of healthcare is poorly suited to single, simplistic, solutions’

The management of healthcare is poorly suited to single, simplistic, solutions; it is intrinsically complex, multifaceted and, crucially, needs to successfully meet varying local health needs.

The requirement to support, enable and facilitate innovation and change at the local level lies at the heart of the review Sir David Dalton is leading on provider models in the NHS. His brief is to “secure the clinical and financial sustainability of providers of NHS care by offering new options for organisational forms”.

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Collaboration and cooperation

There is a clear consensus that to ensure long term clinical and financial sustainability, providers need to rapidly move to different, more integrated services built around patients, and placing greater emphasis on care closer to home. This will require much greater collaboration and cooperation between providers than we currently see.   

At the moment, we tend to major on a small number of NHS provider organisational forms:

• standalone foundation trust and trusts;
• full merger; or
• the sole example of a management franchise.

Yet, as other sectors have shown, there is huge benefit to be derived from using a wider variety of organisational models to collaboratively deliver services, including federations and networks, and joint ventures and special purpose vehicles.

‘There is huge benefit to be derived from using a wider variety of organisational models to collaboratively deliver services’

A new joint publication from the King’s Fund and the Foundation Trust Network, Future Organisational Models for the NHS: Perspectives for the Dalton Review - launched today - looks at the evidence base for introducing these different models. It draws on a range of perspectives including from that used such models in the NHS, in international healthcare and in other parts of the UK public sector like school academy chains and retail.

The document shows that when you look carefully inside the NHS these models are actually being used more frequently than might be immediately apparent. Their use is just not particularly well publicised and is often at the individual service line level, as opposed to the whole organisational level.

More a la carte

It also shows that there is a range of barriers – both perceived and real – that are preventing the more widespread use of these collaborative models.

Examples include the often mistaken perception that their use will trigger competition concerns; and the real issue of time and cost to obtain regulatory clearance for those models that do require approval, such as organisational mergers.

The document shows that, if we are to ensure the degree of provider collaboration and cooperation required, we need a broader range of models; a more extensive “a la carte” approach, as opposed to the current, limited, set menu.

‘A more extensive “a la carte” approach is needed, as opposed to the current, limited, set menu of models’

And the menu analogy is particularly apt as it must be for providers – in consultation with their communities, partners and commissioners – that choose whichever organisational structure they believe will best meet the needs of their local population. There is no single, top-down solution here.

Our publication explores the range of models available. These include:

• “buddying” successful providers with those in difficulty;
• franchising the management of NHS hospitals and services to other organisations;
• building formal and informal networks and alliances;
• creating new joint ventures and special purpose vehicles;
• undertaking organisational mergers and acquisitions; and
• assembling both single service and whole organisation management chains.

Leadership is key

While there is experience to support the use of all these models in different contexts, much depends on how they are implemented in practice.

We also have no evidence, as yet, that one approach is demonstrably superior to the rest.

It is clear that successful leadership is key to effective implementation. Leadership in the NHS needs to be both collective and distributed.

It is just as important in the frontline teams delivering care as it is in boards responsible for running NHS organisations.

‘The impact of different models depends on the ability of leaders to bring about long term changes in culture and behaviour’

It needs to be developed across organisations and areas where networks and chains are involved. And there needs to be much greater continuity of leadership in place of the constant chopping and changing that has bedevilled the NHS in recent times.

The skills required to lead different organisational models are often different from those required to run a successful single institution. This reinforces the wider point that the leadership skills required to drive organisational change will become ever more important.

The impact of different organisational models depends particularly on the ability of leaders involved to bring about the long term changes in culture and behaviour on which sustainable improvements in performance depend.

The Dalton review offers a timely and valuable opportunity to discuss how to support the wider range of provider organisational models the NHS will need in future and the evidence in the report is intended to inform that discussion.

Chris Ham is chief executive of the King’s Fund and Chris Hopson is chief executive of the Foundation Trust Network