Radical policy shifts are needed to deal with some hefty obstacles standing in the way of major change, write Pete Murphy and colleagues

Dave buchanan

Dave Buchanan

Dave Buchanan

Textbooks claim that change is easier to implement when there is a sense of urgency. The Health Foundation notes that the NHS faces “a perfect storm” and an “impossible climate”.

The Public Accounts Committee says that government has “no convincing plan” for addressing the £22bn funding gap. So there is no problem finding a burning platform to trigger transformation.

Would that it were so simple. The textbooks also argue that changes must be designed to fit the context, rather than use standard “building blocks”.

NHS providers face what could be described as a wicked context

Pete murphy

Pete Murphy

Pete Murphy

But what if the context itself is configured in a way that obstructs change? Apart from money, there are many other contextual problems demanding leaders’ attention: chronic staff shortages, the uncertainty and conflicts of interest from constant reorganisation, poor relationships with partners, burdensome and intrusive regulatory systems, no time to test new ideas, and a culture that is far from fault tolerant.

Healthcare is also subject to unpredictable shocks, both internal (Liverpool Community Health) and external (epidemics), and the service is now suffering from the loss of goodwill among junior doctors and experienced nurses.

Phil considine

Phil Considine

Phil Considine

NHS providers face what could be described as a wicked context, a term borrowed from the idea of “tame and wicked problems”. Tame and wicked contexts look like this:

Tame contextWicked context

No staffing problems

Chronic shortages of skilled staff

Stable structures, roles and responsibilities

constant reorganisations and uncertainty

collaborative partner organisations

adversarial relations with potential partners

few regulators with clear remits

many agencies with changing demands

time and resources to test new ideas

no time to test before implementing

failures are learning opportunities

failures mean sanctions and intervention

Is the NHS context wicked? The senior leads in the East Midlands to whom we have spoken seem to think so.

Their views suggest that the prospects for transformation are poor.

A finance director said: “This is an accurate reflection, and I can only see the situation getting worse. The vanguards that will implement the Five Year Forward View give us hope that integration, joint agendas and working are to be encouraged, but the system rules and legislation get in the way.”

I can only see the situation getting worse

And a senior HR lead said: “The organisational structures add complexity, and lack of clarity in terms of accountability. In this context incremental change is very difficult, let alone transformation. Senior leads need time and support to improve performance, and not sacked or threatened if performance gets worse for a period.”

The demands and distractions in a wicked context encourage a focus on problem-solving and fire-fighting. This diverts attention from designing, planning, communicating, resourcing, and implementing major changes. Three other factors can turn this into a super-wicked context:

super wicked context

resources not keeping pace with rising demands and expectations

despite successes, the system is always failing on some measures

those who are responsible for “taming” the context are actually making it even more wicked

Iron triangle or square wheel?

The probability of systems failures increases in a wicked context. Health economists emphasise the “iron triangle” of access, cost, and quality. Try to improve any one of these, and the other two suffer, in the absence of disruptive innovation to “break” the triangle.

The NHS may be driving towards its new destination in the wrong vehicle

Patient safety adds another dimension. The recent history of NHS crises and failures ticks all four boxes.

In today’s wicked context, the transformation agenda seems to be fitted with a square wheel, not an iron triangle. The NHS may thus be driving towards its new destination in the wrong vehicle.

Let’s be friends

What are the chances for more integrated working? One chief executive defined partnerships in the NHS as, ”the temporary suspension of mutual hostility in pursuit of otherwise inaccessible funding”.

Another senior lead said: ”There needs to be shared objectives and a high degree of trust between all parties. The latter is easier said than done as too many people play politics with both a small and a big P”.

There needs to be shared objectives and a high degree of trust between all parties

Recognising the problems, building and maintaining friendships and alliances is a key strategy for managing in this wicked context:

”We have focused on delivering our own transformation goals, tried to stay in the middle of the pack rather than at the outer edges, and worked on relationships so that if the proverbial hits the fan we have some allies and friends.”

”Build relationships with key individuals, focus on a few key priorities, concentrate on culture and staff wellbeing.”

System shifts

Radical policy shifts are required to reshape the context in order to support transformation.

Suggestions from our sample of leads include: rewards for integrated working; time for performance improvements; Department of Health and Care Quality Commission supporting and helping, not inspecting and criticising; fewer measures of success; merge CQC and NHS Improvement; abolition of payment by results, along with personal health and social care budgets; competition and tendering as the option of last resort; better access to medical schools to increase the supply of junior doctors; and ”we need to say “No” to a few things nationally”.

These changes would nudge the context towards the “tame” end of the continuum, and allow providers to point to the burning platform, to exploit the sense of urgency, and to confront the perfect storm with real, sustainable transformation.

Pete Murphy, Phil Considine, and David Buchanan are with Nottingham Business School Healthcare Management group, which is about to launch a wider study of the prospects for the transformation of healthcare in the region. A conference to present findings, to examine the strategic implications, and to identify ways of incorporating the findings into medium and long term healthcare planning at both a regional and national level will be held at the Nottingham Conference Centre in September.