NHS targets: from compliance to commitment

This month, I had to select the “article of the month” for the NHS Institute website. I try hard to stay up to date with the latest thinking and research on healthcare improvement and large scale change so my colleagues were surprised that I chose an article that was first published 25 years ago. It is “From Control to Commitment in the Workplace” by Richard Walton which appeared in Harvard Business Review in 1985.

I chose to highlight this piece because it is very “current” in its message. Essentially, Walton says that frontline staff do not respond effectively or creatively to change when they are set tightly specified goals from on high, in situations where senior leaders seek to exercise control to achieve efficiency and consequently, where those staff responsible for delivery feel they have little voice or power in making decisions about their own work. Rather, Walton champions an approach where leaders seek to enable their staff to lead their own changes, to build the commitment of the frontline and create the conditions where that commitment can flourish. Walton describes these differences as reflecting the choice between a strategy based on imposing control and a strategy based on eliciting commitment. He says that this commitment is a critical component if we want to achieve world class performance.

Fast forward a quarter of a century. We can update the model by talking about compliance versus commitment but it is the same basic principle. Essentially, compliance organisations rely on rigid hierarchies, systems and standardised procedures for coordination and control. In commitment organisations, the co-ordination and control mechanisms are based on shared goals, values and sense of purpose.

Over the next period, the NHS will be moving away from a “compliance” system based on top-down national targets and standards. However, if we remove one mechanism for co-ordination and control, we need to replace it with another. I want to make the case for “commitment based” approaches to change as the alternative.

The evidence in the large scale change literature suggests that healthcare organisations and systems are much more likely to deliver sustained transformational change through commitment than through compliance. Even in situations where challenging goals, standards and policies have to be adhered to or achieved in short timescales, we are more likely to get better, quicker results if the accountable leaders do so on the basis of commitment to the bigger purpose. Commitment approaches build motivation, which is the best possible starting point for mobilisation for change at scale. People who are highly motivated are more focused, persistent, willing to take risks and able to sustain high energy. In the context of clinical engagement, there is a correlation between clinicians who are engaged and motivated and high performance in almost every dimension, including patient outcomes and mortality (NHS Institute, 2009).

The McKinsey researchers, Lesley, Loch and Schaninger (2007) reach similar conclusions to Walton. In their large scale study of incentives in organisations, they found that creating an environment that encourages openness, trust and challenge and broad, stretching aspirations that are meaningful to people are far likely to motivate the workforce to improve than other things that people think of as performance incentives such as key performance indicators, standardised control or “stick and carrot” approaches.

In my opinion, one of the biggest priorities for NHS leaders in the era of QIPP is to build the foundations for a commitment-based quality and productivity strategy. Understanding how leaders in other sectors and situations have met the challenge of commitment-building is essential learning for NHS leaders who want to create purpose for their workforce in a world where traditional management levers like hierarchy are diminishing, within an environment that is increasingly complex and volatile.

In the spirit of Walton, I have compiled a table that compares “commitment” goals with “compliance” goals for the NHS. Compliance goals have been prevalent in the NHS over the past ten years. As we move to the new era where goals and aspirations will be more locally determined, it may be a challenge to get consensus on local commitment goals if our clinical leaders think they are setting compliance goals and that they will be held to account for them in the old way. We will not be able to build the relationships we need to deliver our goals if we don’t make the distinction.

Delivering our NHS goals on quality and cost improvement will require a massive strategy of commitment, not just compliance. Commitment comes from the heart as well as the head. It is about making a connection with the purpose that led each of us to choose to do the jobs we do. Therefore, in order to build a commitment strategy, we need to think deeply about the meaning of what we are asking people to sign up to. It is a higher purpose than delivering quality and cost improvements (although these are vital). It is about helping to create a future NHS that we would want to support our own families and that we would want to work in. Shared values are a pre-requisite for the commitment, courage and sense of common purpose required for the next stage of NHS transformation.

Thank you Richard Walton for your inspiration and wisdom which is as relevant now as it was 25 years ago.

References

Leslie K, Loch M and Schaninger W (2007) Managing your Organization by the Evidence, McKinsey Quarterly, no 3

NHS Institute for Innovation and Improvement (2009) The Link between Medical Engagement and Performance, http://www.institute.nhs.uk/building_capability/enhancing_engagement/medical_engagement_and_organisational_performance.html