Humpty Dumpty’s declaration in Lewis Carroll’s book Through the Looking Glass that “when I use a word it means just what I choose it to mean” must have rung a bell with delegates at the recent NHS Confederation conference in Liverpool as they listened to the proposal by the NHS England chief, Simon Stevens, to introduce “success regimes” in three failing localities – North Cumbria, Essex and parts of Devon. It might not be as daft as it sounds, but will it work?
A briefing paper from NHS England describes the targeted localities as having deep-rooted and long-standing difficulties that are in need of transformation. The health and care economies of these places will find themselves overseen by NHS England, Monitor and the NHS trust development authority plus others when deemed appropriate. Problems will be diagnosed, required changes identified and implementation plans agreed.
The initiative is not without merit. In particular it recognises the need to look at local systems rather than focusing upon the problems of single organisations – a feature that distinguishes it from previous programmes such as special measures for NHS trusts and foundation trusts.
However, despite talk of a health and care economy, the proposal seems at worst focused upon hospitals and at best on the relationship between secondary and primary care. No reference to, or understanding of, the link between health, social care, housing, neighbourhood, transport, employment, deprivation and other determinants of wellbeing is evident.
A second apparent merit is that whereas previous measures threatened intervention, the new model also offers support. The problem is that this is being offered in traditional top-down NHS style by regulators with a reputation for command and control rather than supportive facilitation.
The threat of punishment simmers away beneath the pleasantries – for example, localities will be placed under the control of an appointed programme director and will be held to account for meeting a clear and agreed timeline.
What might a better model look like? First and foremost it needs genuine and skilled service improvement agencies offering the support, not regulators. Unfortunately England’s improvement agencies are a mess. Two of the bodies that might have developed into key contributors – the Care Services Improvement Partnership and the Integrated Care Network – were summarily killed off in the coalition’s 2010 quango cull.
Those left – NHS Improving Quality, the NHS Leadership Academy, clinical senates, clinical networks and academic health science networks – tend to have a narrow, even clinical, NHS focus and are currently the subject of a restructuring that will, paradoxically, be overseen by the regulator, Monitor.
This disinvestment in improvement service activity has not been the case in Scotland where, for the past 10 years, the joint improvement team (Jit) has developed a model of service improvement with three components – people, context and complexity.
People
The key to service improvement is not legislation, governance or threats but people – ensuring the right people are in the right place at the right time to offer support.
Jit has over the years built up a cadre of trusted and experienced people (full and part-time) who command respect in local partnerships by virtue of their own experience and skills. These people serve as boundary spanners, behave neutrally, adopt a facilitative style and act as critical friends. England, on the other hand, has tended to parachute in hit squads of expensive and unwelcome management consultants.
Context
Effective service improvement requires a genuine understanding of the local context – the stories, personalities, histories and dilemmas – and this in turn requires a routine local presence to dig deeply and uncover narratives.
Unlike regulators, improvement colleagues will be accepted into local policy and practice networks on the understanding that they are there to help not judge, to support not threaten. Jit has a local presence in every one of Scotland’s 32 local partnerships, whereas
England is adopting short-term targeted intervention.
Complexity
While the Stevens model espouses the need for a whole system approach, it is unclear whether it comprehends the messiness and unpredictability of complex adaptive systems.
In the Jit model there is recognition that problem areas are shaped by multiple causes that interact in unpredictable ways, and that an improvement body simply has to work with this complexity. In England, on the other hand, there still seems to be a belief that a regulatory agency can somehow impose a linear solution.
It would be wrong to think that the Scottish model offers all the answers – indeed the Scottish government is in the process of restructuring its own multiplicity of improvement agencies, including Jit. However, the overarching message that the service improvement task is a complicated long-haul not a top-down quick fix is an important one for England.
Unless this is grasped we could end up like the queen in Through the Looking Glass – believing as many as six impossible things before breakfast.
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