The Spending Challenge was launched last week; it provides the opportunity for all public sector employees to highlight their ideas on how to reduce the deficit.   Assurance has been given that all ideas will be read.  It seems, according to the web site that suggestions have been flooding in. 

Ideas should be many because there are numerous people working within the NHS who have good ones.   I hope that a sufficient number of people are made available to read the ideas, that those that read them understand the NHS, and that any that might appear unpalatable are not instantly dismissed.   I don’t really mean unpalatable, I just mean hard that’s all - not impossible, crazy or ludicrous, but just plain hard.  

Bearing in mind it seems that in the past political tendency is to back down over the first smidgen of pressure (particularly over very emotive issues) I can only trust that being asked ‘Don’t hold back. Be innovative, be radical, challenge the way things are done. If you think you can make things better for less money don’t just complain to your colleagues about it - tell us about it so we can make it happen’  is an accurate message.  We will see, we can hope.

Time and time again, a theme which seems to not only run through organisations, but which underpins the delivery of many initiatives, is the need for this thing called ‘cultural shift’.  But what is this cultural shift?  It’s not an object or something that procurement or a drug company can provide and there is no text book answer as to how to achieve it (there probably is actually). It is not directly about achieving best in class productivity, although this would definitely be a positive consequence, but it is about shifting mindset and this is more difficult than anything else.  There are many studies of best practice and how productivity can be improved, similarly there are examples of different ways of working and using IT to be more efficient, but to deliver these changes we have to do something.  

The challenges with changing mindset are many; some are steeped in tradition, some really don’t think they need to change and some, whilst not necessarily liking the way things are done now, don’t really want to change because it will be hard work and will require compromise.  Add to this the length of time and effort changing culture might take and it’s enough to turn anyone off - we like quick wins in the NHS and think mainly in the short term.   If however we address this now we might, just might, improve the NHS for the future.  

Talking about change isn’t going to deliver change and conducting more studies isn’t going to help either; much of the evidence is already there, so whilst to some this might sound soft, fluffy and perhaps basic, I think one of the key things to address is mindset - everyone’s mindset.   Leaders need to lead and decide whether they want and are capable for leading in these challenging times and if they are they need to hold their teams to account and challenge the status quo, even in disciplines which have historically been hard to challenge.   Managers need to do the same thing; hold people to account and think radically about how to deliver care in the new world.  Strong co-ordinated leadership is needed across a number of organisations from the very top through to local levels to start addressing the issues that we know will make a significant difference.  The difficulty is that this is tricky, political and challenging which is the reason we have mainly shied away from addressing it in the past.  We can’t and must not anymore.     

We have a tendency in the NHS to write endless plans about how to achieve savings and deliver efficiencies (I am not meaning to sound disparaging, I too have done this many times), some are purely a paper exercise and managers round the country hope that by hook or by crook plans are delivered, or if there is slippage in one scheme something will happen midyear in another which still achieves balance at year end.    We spend a lot of time and effort planning and to be frank some things do not need planning, some things just need doing. 

Savings and change on the scale needed now are simply not going to be possible without all people working in the system realising that things will have to be done very differently.   This means everyone, all disciplines, even those who might appear a little resistant to change need to accept this.  Hope is not enough.    It will need compromise and it will mean that many disciplines might make changes that will impact on them in some way, but for the NHS as a whole these changes will be necessary.

Let’s not be too despondent though, there are many good news stories and areas of incredible innovation and improvement where investment (time and effort mainly but sometimes money) has enabled significant change; improved quality and efficiency to services.  These areas are generally where people delivering care truly work together across boundaries, are really held accountable and take personal responsibility for their role.   This isn’t just about having the right structure in place; it takes a conscious effort to work as a team not as an individual.

I genuinely don’t think many people fully understand how difficult this is going to be (of course some do, but many hear the words but don’t appreciate that it will apply to them).   Delivering savings of the scale required is going to be really tough.   We have a chance now to deliver some of the changes and improvements that we have known we need to do for years - there wasn’t an excuse before but there certainly is no excuse now.   Why, when hospitals know that they are not as good as their peers; when they are not as productive as they could be and could make significant quality and efficiency improvements do they not address this?   This is about all of us doing our bit.  There seems little point in waiting for someone to tell us what to do because the problem is that people don’t really know.  

There will definitely be a negative impact on quality of care if inappropriate savings and cuts are made.   No one wants this but what people seem not to realise is that they can make sure this doesn’t happen.   It’s not all about the politicians.

By the time the Spending Challenge has been assimilated and discussed we might be 6 more months down the road, it will be April 2011 before we know it, although I still think it is useful to input into the process.   A wing and a prayer will not deliver savings on the scale needed, neither will endless plans.   What we need is to not only start delivering what we have been talking about for years, but to also address the changes in culture needed; make some bold decisions, weather the storm and stick with it however hard it will be.