What can be learned from high-performing health organisations? This is the topic we will be discussing at an event at the King’s Fund on Tuesday. My recent review explored how high-performing NHS organisations might lend their support to providers in difficulty.
It supports NHS England’s intent to get NHS providers to think beyond their existing boundaries so that they can deliver high quality services, reliably. As the NHS Five Five Year Forward View says, NHS providers should be clear on the models of care they wish to create and the design principles they wish to pursue. Then it follows that they need to determine the governance arrangements to deliver the desired change. The future sustainability of the NHS requires greater vertical integration between primary, social and secondary care and greater horizontal integration between hospitals. NHS providers need to create new strategic plans to organise the delivery of this change.
Most healthcare organisations in other countries have an enterprise strategy, and a mindset for change, growth and development, but you don’t often see this in the NHS. The European systems I visited are characterised by standardisation, initially of back-office functions, but increasingly covering procurement, care pathways, innovation and improvement methodology enabling new technology and devices to be deployed, at scale, across different sites, to improve care quality and bring service reliability and significant efficiencies. There is a relentless drive for high reliability, to minimise operational variability.
Collaboration should be viewed in terms of what’s best for the patient, rather than its impact upon organisations. Nobody should camouflage their resistance to changing patterns of service by stating “it’s not in the patient’s interest”, when what they mean is that it is not in the interest of their organisation. Providing reliable, high quality services must be the driver for change – and not the preservation of organisations.
NHS providers should rethink the outmoded “single organisation” mindset, where it is expected that every service should be provided from a single site. For example, to meet the requirements for 24-hour, seven-day-a-week emergency surgery will require collaborative solutions across more than one organisation. I have suggested that a “joint venture” of a number of hospitals creating single shared services, operating across a number of sites, serving wider populations offers a solution. By pooling the specialist workforce and facilities we can organise for patients to receive a standard of service that is currently not available to them. By ceding some sovereignty for the management of a service and pooling their governance, trusts can benefit from shared risks and benefits. The NHS is able to operate joint ventures to operate laundries and run incinerators, and yet it struggles to do the same for clinical services. My review recommends how this could be changed.
It states there is significant variation in the standards of service provided by our healthcare organisations and that we should act now to reduce this variation. The Care Quality Commission and regulators can identify those organisations in persistent difficulty. The buddying arrangements introduced for trusts in “special measures” should be expanded to allow organisations in difficulty to benefit from support and improvement that can be offered by successful trusts.
The review recommends that those organisations able to demonstrate a track record of high performance should be encouraged to consider managing an organisation in persistent difficulty through a long-term management contract. This would be a quicker transactional solution than a merger and would not require the transfer of staff and assets to new ownership.
Successful NHS providers, who develop their enterprise strategy, should be capable of demonstrating how they would deploy their leadership model, their systems and their methodologies into other organisations. They will understand their assets and their technologies and they will be keen deploy these. They will probably work with other partners to utilise expertise they do not have. They will undoubtedly be wishing to consolidate back office functions to create economies of scale.
Successful trusts experience no reward for their achievements, other than pride in a job well done. They cannot (and should not) increase their prices in the way that they could in a market, and so I believe there should be opportunities for them to be rewarded for their success through spreading their tried and tested systems into organisations in persistent difficulty. Incentives will need to be provided at a sufficient level for this reward to “feel real”. We should not be embarrassed by this concept – as the current practice is to “reward” external management consultancies for their efforts to turn around organisations or to remove chief executives and executives and replace them with untried alternatives. Rewarding successful organisations would at least allow opportunities for their success to be adopted and spread elsewhere.
Leaders of our NHS organisations must now design high quality and sustainable models of care which serve the interests of patients. New ambitions and a social entrepreneurial flair should create the governance and organisational forms to enable the delivery of these. These are exciting times.
