The story of the three little pigs has echoes in the recent Healthier Together judgment at the High Court, says Alex Heritage 

As the dust settles on last week’s High Court judgment it offers a timely opportunity to reflect on the impact. The Manchester decision acts as a warning sign to the rest of the NHS.

It is now clear that to achieve financial and clinical sustainability we must shift from single organisational fixes to whole system solutions. This requires a different approach, fraught with complexity. The story of the three little pigs provides a simple example of how the NHS typically approaches large change, with many people unfortunately being eaten by the wolf.

The Healthier Together programme involves all 12 Greater Manchester clinical commissioning groups and changes to eight of the NHS acute trusts. Predominately focused on emergency care, the programme is supported by changes to primary and adult social care. Last July the 12 CCGs decided that Wythenshawe Hospital in South Manchester would lose its emergency and high risk general surgery. This was challenged by a group of doctors,Healthier Together’ who formed a private company to pursue the judicial review.

On the face of it, the Healthier Together changes could be seen as straightforward, involving small numbers of patients across Greater Manchester. In practice the programme has commanded the highest level of leadership, four years of planning and ultimately ended up in the High Court. There have been significant challenges through the years and the ‘Wolf’ has always been waiting to devour the programme. These brief reflections aim to assist others build a solid structure and succeed in a complex world.

’Too many NHS changes rush to build a programme driven by a financial or clinical imperative. This haste is often followed by an approach of add-on to the day job’

Passion and storytelling

Healthier Together faced many challenges throughout the years: initially gaining trust with senior clinicians to describe the need for change, launching a public consultation months before a general election and most recently defending the unanimous decision before a High Court judge. At every challenge, energy and resilience was drawn from the belief that the changes were needed.

Often these changes were articulated by the power of storytelling. Senior clinicians, chief officers and patients stood on many platforms and told their personal story, humanising the proposed changes and conveying their passion. Change that is not grounded in a true belief of change with individuals willing to personally share it will struggle to survive the many attacks that will come.

Straw and sticks

Too many NHS changes rush to build a programme driven by a financial or clinical imperative. This haste is often followed by an approach of add-on to the day job, rather than seeing transformation as core business. The Greater Manchester CCGs acknowledged the scale of their changes and invested in dedicated resources to work on their behalf.

This was supported by a specific organisational development plan committing time and energy to developing relationships and supporting senior clinicians through the change cycle. All the right people can sit in the room together, a PMO can produce the required documents and collective name for the work can be agreed. However, failure to commitment the dedicated resources, time and acknowledgement to the complexity of transformation will see the straw and sticks quickly tumble.

Solid structures

Nowadays, the little pig that built his house of brick would no doubt be criticised for taking too long, spending more money and delaying the needed outcomes. The Healthier Together programme was built on a solid foundation of belief and personal commitment to it. However, the structure came from solid governance that was proved invaluable in preparing for court.

‘People embarking on transformation should ensure the governance, infrastructure and production of materials holds up to professional scrutiny’

It only dawned on me during the first day of the hearing that every document, appendix, email and publication will be forensically scrutinised by the barristers and used to attack the programme. The programme had generated thousands of documents over the four years and the disclosure extended to all partners involved.

Large scale programmes now exist in a complex environment of policy, regulation and public law. People embarking on transformation should recognise this fact and ensure the governance, infrastructure and production of materials holds up to professional scrutiny. This should not act as deterrent to be radical and innovate; the NHS needs more of it.

It is hard to identify an organisation or place that will look the same in 2020. Therefore it is a realistic warning that transformation will be challenged, especially when it involves many partners. Solid structures should enhance the likelihood of success.

The story of the three little pigs may be a children’s fairytale but it offers a simple message for those charged which changing the NHS: build the right house or get eaten by the wolf.

Alex Heritage was the programme director for Healthier Together and is now the chief operating officer of the Transformation Unit. Details of the Healthier Together programme can be accessed at