A survey of chief executives reveals insight into what they believe can make a foundation trust excellent, report colleagues at Finnamore.

All remaining NHS trusts will be expected to become foundation trusts “as soon as clinically feasible”, and in line with an agreed deadline.  At the same time, the challenge facing the NHS to meet growing demand, at higher quality, within a decreasing financial envelope and in the face of private competition is very real.

In the face of the greatest challenge the NHS has ever faced, will only the very best succeed?

Jim Collins’s book Good to Great addresses a single question: can a good company become a great company, and if so, how? Based on a five-year research project comparing teams that made a leap to those that did not, Good to Great shows that greatness is not primarily a function of circumstance, but largely a matter of conscious choice and discipline. 

Collins’s definition of a “great” organisation is one “that makes a distinctive impact and delivers superior performance over a long period of time”.

At Finnamore, we conducted a survey of NHS chief executives in order to take a snapshot of their thinking on some key questions at this important time. The aim was to gather some qualitative views about the following:

  • What are the most admired foundation trust characteristics?
  • What are the most important new characteristics that FTs will need to demonstrate, and how can they develop them?
  • What are the most significant obstacles facing NHS organisations, and how can these be overcome?

Profile of survey respondents

In all, 20 chief executives completed the survey. The majority of respondents were from acute providers, a third from an integrated provider and one was from a mental health trust. Three quarters of respondents were the chief executives of a foundation trust, most of which were authorised as an FT by 2007.

When asked to rate the performance of their own organisation, 20 per cent felt it was excellent, 55 per cent good, and 25 per cent OK. No respondents described their trust as challenged.

Summary of responses

There is broad agreement among chief executives about what characterises a great, or excellent, FT:

  • Provision of high quality care.
  • Having a patient-centred culture.
  • Being financially sound.

The characteristics FTs need to develop over the next few years:

  • Being flexible and responsive to the changing health care environment.
  • Developing effective partnership working with commissioners and providers.
  • Becoming more market-aware.

And the obstacles that FTs are likely to face going forwards (see diagram 1, attached right):

  • Meeting the financial challenges.
  • Opposition from the public, politicians and the press to service changes.
  • Lack of strong commissioning or system management hindering strategic planning.

Survey responses: What characterises a great FT?

Respondents were asked the following questions:

Thinking of a current FT you admire, what three characteristics do you admire most?

Please elaborate on why you see these characteristics as being of primary importance.

The responses were collated and ranked (see graph 1, attached right). The three characteristics most consistently admired were:

  • Provision of high quality care.
  • Having a patient-centred culture.
  • Being a financially sound organisation.

Having a good reputation and consistently strong performance were also viewed as important, as well as having inspiring and stable leadership and an innovative approach.

The reasons why these were felt to be important are described below.

  • Quality of care and having a patient-centred culture.These will become key drivers of the market, as patients will increasingly choose Trusts based on the quality of care and patient experience they receive.  Organisations will need to maintain and increase their focus on quality and safety of care, and reward staff for promoting a patient-centred culture.
  • Being financially sound is essential for current and future viability, compliance with Monitor’s requirements, and provides a solid foundation for any future developments.
  • Both of the two previous points will improve a trust’s reputation; delivering excellent outcomes and striving for excellence will increase the trust’s reputation with patients and commissioners. Developing positive external and internal relationships will inspire trust and create a climate within which the trust can thrive not just survive.
  • Innovative approaches to practice, and developing creative solutions to problems will strengthen the trust’s ability to respond to changes and challenges in the market.
  • A strong and stable leadership team will be able to set a clear direction and vision for the Trust, will motivate staff to deliver the vision, and inspire confidence and trust from external parties.

Other areas felt to be important were:

  • Consistent high performance across all areas, to develop and maintain the trust’s reputation.
  • Having a good understanding of, and focus on, the trust’s core business and strategy can provide a sense of purpose and focus to drive performance improvements.
  • Staff engagement and loyalty were both regarded as important for successful performance. Using the FT membership effectively can enhance the trust’s reputation.

FTs are absolutely right to focus on the quality of care and a patient centred approach.  In our experience, improving quality drives down costs, and satisfied patients will secure or increase income: a “win-win” for patients and the FT.

What new characteristics will FTs need in the future, and how will they develop them?

Respondents were asked the following questions:

What are the top three most important new characteristics that excellent FTs will need to develop?

What steps will NHS organisations need to take to develop these characteristics?

The responses were collated and ranked (see graph 2). The most significant new characteristics seen as important for FTs in the future are:

  • Developing flexibility and responsiveness to the changing healthcare environment.
  • An ability to work in partnership with others, including commissioners.
  • Better market awareness including customer focus and improved marketing of services.
  • A continuing focus on quality and patients was also seen as important, including patient safety, experience and outcomes.

In addition, having a more innovative or radical approach to service delivery was seen as important, as well as improved marketing skills.

Suggestions for how organisations can develop these characteristics are set out below.

Developing flexibility and responsiveness to the changing healthcare environment was seen as the most important characteristic that FTs need to develop. Partly this can be developed through effective partnerships with commissioners and other providers, and through being more market aware and being able to respond to changes in the market place.

Respondents suggested some specific actions that may help to develop flexibility and responsiveness: 

  • Ensuring a culture that enables and supports staff to move quickly to change services according to patient need, choice and wants and actively encouraging a culture of innovation and entrepreneurism.
  • Including key service shapers in developing and implementing the strategy will help drive change through the organisation.
  • Driving service improvements against best in classin order to improve service focus.
  • Developing a preparedness to take risks – this may help FTs to be politically astute in how to do, rather than what to do.
  • Develop a can do approach as an organisation. Take organisation development seriously, including leaning lessons from outside the NHS.
  • Staff engagement could be improved by learning from organisations outside the NHS (the ‘John Lewis model’).
  • Leadership should be developed throughout organisations by developing leaders at all levels.
  • Strengthening “community governance” and developing greater local accountability and ownership could be achieved by developing new governors, governance structures that are fit for purpose and demonstrating democracy in decision making.
  • Financial stability, good CIPs that are delivered and good planning may all help to improve organisational ‘resilience’.

FTs will need to respond to local health needs by developing their ability to work in partnership with others – both providers and commissioners. Important actions will include developing mature conversations with commissioners about how the organisation can sustainably respond to the needs of the local health economy – this may involve ceasing to deliver some services.

A majority of respondents noted the importance of greater market awareness and improved marketing of services in order to better meet customer needs.  Numerous actions will likely be needed to ensure a through and robust response to customer needs and to the market.  A number of specific suggestions were made:

  • Equipping staff with timely and accurate financial and activity information can help to increase their understanding of their service as a business, and increase their market-awareness.
  • Development of staff knowledge and expertise in markets and health economics will be important, to help shift the mindset from “public sector to market sector”.
  • Improved marketing of services could be achieved by recruiting individuals with marketing skills and expertise and by shifting the mindset of the workforce from ‘public sector to market sector’, although this was noted as being a significant challenge. 
  • Development of higher business level expertise could help lead to the perception of healthcare as a commodity or product throughout the organisation.

A number of responses had a continuing focus on quality and patients at their heart, with a number of suggestions for how this can be achieved. These suggestions included:

  • Developing patient-centred care and a focus on outcomes – involve patients more, and in a more meaningful way, and make it a part of the organisation’s culture. Real-time measurement of, and response to, patient experience is a way of achieving this.
  • Customer focus– a sustained cultural revolution may be required in order to achieve this, with customers also needing to be involved in a more meaningful way.
  • Improving patient safetythrough the development of more robust clinical networks and by empowering front line staff and promoting a more approachable ‘management style’.
  • Improvements in qualityshould be led from the top with the setting of more ambitious standards.
  • Improved relationships and partnerships may help to improve the patient experience.

Most significant obstacles facing NHS organisations

Respondents were asked the following questions:

  • What do you see as the three most significant obstacles facing NHS organisations making the journey to excellence in the next three years?
  • What are the three most important changes that NHS organisations should make to overcome these obstacles?

The responses were collated and ranked (see graph 3, attached right).

The three biggest perceived obstacles to achieving excellence over the next few years were:

  • Meeting the financial challenges, including the reductions in local authority funding.
  • Public, political or press opposition to changes to service delivery.
  • The significant changes in commissioning arrangements - both by causing a “planning blight” for current commissioners, and also the inexperience of emergent GP commissioners.

A theme also emerged in the responses around the workforce challenges facing FTs.  Some respondents highlighted the challenge of resistant workforces that can be unwilling to change, a significant challenge around clinical engagement, and a perceived inability to inspire the workforce.

Some also felt that a lack of active system management and disjointed strategic planning are obstacles. Others pointed to the pressures of regulatory demands, a lack of ambition, private sector cherry picking, and to the need to focus on quality.

Respondents made a number of suggestions for how FTs can make changes in order to address the challenges they face. 

Up to 18 per cent of respondents highlighted responding to the financial challenge, including the reduction in local authority funding, as one of the most significant obstacles facing NHS organisations. Several suggestions were raised as ways of overcoming this obstacle:

  • Improved efficient working or getting into shape.
  • Specific suggestions around squeezing costs.
  • Demonstrating value for money (especially where “more for less” is not an option).
  • Reducing spend on redundancy.
  • Establishing clear spending priorities. 
  • A change to financing arrangements such as establishing bridging funding arrangements.

It was also noted that wider publication of what works and success stories in this area would be helpful in order to spread good practice.

Linked to the need to make service changes in order to both meet the financial challenge and improve quality, 14 per cent of respondents pointed to the importance of responding to the challenge to engage with the public, the media and politicians.  Respondents felt that this challenge could be met through:

  • Better communication, including earlier involvement of the public in a more honest way, and a clearer articulation of the consequences of inaction. 
  • Great strategic planning was seen as crucial in responding to the challenges posed by public opinion. 
  • Good intelligence would enable FTs to work through the plan that is needed to meet the challenge of public opinion and start to deliver it in the hope that it will be endorsed.

Responding to commissioning challengeswas seen as a key challenge in two main respects – immature commissioning teams and decisions as a result of changes in both national and local commissioning arrangements, and the risk of “commissioning blight” as these changes are implemented.  Suggestions were:

  • In dealing with immature commissioning, there were suggestions that collaboration between neighbouring trusts could potentially present a more united front in respect of commissioning intentions. 
  • Developing more supportive and helpful relationships with leading GP consortia.
  • Offering support and developing strong clinical networks. 
  • From a pragmatic perspective, building in provision for delays in decision making was seen as prudent by some. 
  • In terms of working through ‘commissioning blight’, again, great strategic planning was seen as important. 
  • Embarking on a programme to identify commissioning challenges and service design solutions to meet those challenges was also suggested. 

There was also a clear theme around workforce challenges, with respondents feeling specific difficulties around clinical engagement, trying to inspire the workforce, trying to promote and encourage innovation at a time of economic pressure, and a resistance to change amongst the workforce.  Solutions included:

  • Using patients, customers, service users as an integral part of the change management programmes.
  • Learning to work with others in partnership.
  • Ensuring there is a vehicle within the FT to bring innovation to the surface and work through whether it is worthy of support. Executive level is needed to ensure resources can be committed.

Solutions to other perceived challenges, such as a lack of active system management, disjointed strategic planning, and the pressures of regulatory demands were also suggested.  These included:

  • Cultivating GPs as customers.
  • Influence ‘externally and upwards’.
  • Get involved in shaping the new system.
  • Partnerships.
  • Strong management of relationships with regulators and lobbying them to streamline their processes.

Good to Great provides clear evidence that the “great” organisations will thrive and prosper in the difficult times, and that the “good” and average organisations are more likely to move from one crisis to another – and many will fail.  It’s therefore imperative that those FTs who have not already started on the “good to great” journey should do so now.  What this research begins to reveal are the characteristics of “great” in the NHS environment and the challenges that will be encountered along that journey. 

From our experience, FTs that will become “great” - and consequently be those that will thrive - will be those that seize the initiative on four fronts:

  • Transform services to become the “right shape and right size”.
  • Focus on quality to reduce costs.
  • Focus on patient satisfaction to secure, or indeed grow, their income base.
  • Adopt a more commercial attitude to how they develop services, broaden their base and reduce their reliance on NHS income alone.