Introduction
In England, NHS services delivered outside the acute sector setting and in the community have often been described as “Cinderella” services, to suggest that they worked very hard, got little recognition and received even less funding. But in these days of radical and ambitious service change in healthcare, where you do not choose improvements from the list of Safety, Quality, Efficiency and Value, but have to deliver them all at once, these Cinderella services may offer the best hope to demonstrate what real transformation is all about.
In the fairytale, Cinderella has mice, a pumpkin, a rat and lizards as essential components for her own transformation. In the real world of the NHS, I believe there are four elements for successful transformation: incentive, experience, flexibility and opportunity.
Incentive
Change always requires effort and often causes disruption. Radical change grows these impacts exponentially. So why bother with the really hard stuff?
Healthcare is no different. Until recent years, real incentives to NHS organisations have been hard to find. General Practice Fund holding did create real incentives – cash incentives – and a lot of radical change did happen over that period.
The growth of the Independent sector and the inclusion of the Third sector as acceptable choices for NHS commissioned care also provide incentives for ambitious NHS change through their ability, in some niches, to offer a genuine competitive choice for NHS Commissioners.
The new Foundation Trusts potentially offer the most incentive to transform, that of retaining the savings made from improved or extended services, but they are constrained in other areas discussed below. Most Foundation Trusts face challenging financial regimes and much of their incentive to transform is driven by attaining financial balance rather than reacting to competitive pressures.
For community services, internal incentives are still very rare; there are no Community Foundation Hospitals at present, but there are still real incentives for change driven by a real choice in the healthcare marketplace. The Independent sector, the Third sector and growing outreach services from the acute sector all threaten the status quo in community services. While fighting for survival is not a ‘pleasant’ incentive, it remains a very powerful one for change.
Experience
A major obstacle to achieving step change is the experience of the people involved. We all have experiences of adjusting our processes or behaviours, whether voluntary or enforced, and the personal experiences we have colour our perspective on future change.
In the NHS, change is mostly enforced, often threat laden and to timescales that rarely match a viable reality. This is a cultural norm; it has been this way for a very long time and is unlikely to change in the near future. Irrespective of the rights and wrongs of this, it does make radical change in the NHS feared, avoided where possible, often viewed cynically and done to a path of least resistance when unavoidable. Couple this with a system where great success is often still not commensurate with great reward and you can understand why the NHS does not rush toward and embrace change. Experience is everything.
Community services, whether they enjoy it or not, have a lot of change experience. Every significant organisational restructuring of the NHS over the last 20 years has profoundly affected community services. Some of the most challenging policy shifts in the NHS, like GP Fund holding, Child and Family Services and PCT commissioning/provider splits, for example, have had massive consequences for community services. While these types of change are rarely pleasant they have been delivered. There will be no NHS organisations that have not suffered with change fatigue; it just appears that community services, through experience, have built up a level of stamina to cope.
Flexibility
One thing that organisations find hardest to control is their inherent flexibility or agility for radical change. This is even harder in public sector services, where decisions are not solely economic. If you think about the four areas where change can occur as people, processes, estate and technology, some elements of the NHS are hugely constrained.
The workforce is substantial and changes to it are emotive and non-trivial. There is no large surplus of workforce waiting in the wings; they take time to recruit and train. The NHS has to broadly work with what is has got and change slowly.
NHS estate is rarely flexible either. Whether that is the commercial limitations of modern build PFI arrangements or an old estate with high maintenance, there are major constraints in what can be done with large scale NHS buildings.
Processes can and should be changed. This is an area where the whole of the NHS can really innovate.
Technology can either create or constrain flexibility; it depends on the technology applied. At this time, the NHS is still awaiting modern technology solutions so the balance is more towards constraint instead of freedom through technology use.
In thinking about flexible adaptive organisations, size does matter. Smaller organisations tend to have more agility – more control over their local change circumstances and a greater potential to adapt quickly. Again GP Fund holding was a prime example of how rapid and profound service improvement could be achieved on a small scale.
Community services benefit in most areas of flexibility. Their workforce is large but is well used to working in new ways and new locations. Their estate is relatively small and they are typically not burdened with constraining PFI schemes. Their processes are as suited to change as anyone’s in the NHS and they benefit from not having too much old technology in place – but are moving towards flexible modern technology in the medium term.
Opportunity
Change may be forced upon organisations rather than made willingly but the acid test of sustainable and useful change is the value that it gives back to the organisation. Even the hardest journey will be undertaken if the rewards are sufficient and the toughest conditions endured if the rewards continue to be delivered.
The NHS is often very good at adjusting the rules to level the field. Look at the NHS tariffs; price adjustments are regularly made in line with market conditions, not just through analysis of true costs. How devastating must it be for one organisation to undergo expensive and painful change to find that its leading position is narrowed because it has genuinely raised the bar but others have not followed? Consider the contracting arrangements with the Independent sector providers of NHS services around volume-based contracts. There is a substantial inequity between how services are commissioned from the NHS and how those same services are commissioned from the Independent sector.
This rebalancing, however politically or financially expedient, does serve as a very powerful disincentive to embarking on radical change programmes.
Community services have advantages here. The requirements of Price Tariffs and adjustments to the ‘system’ are not as advanced and intrusive as they are in the acute sector. Additionally, the partner-based working practices in community services, often with non-NHS agencies, complicates these system re-adjustments and makes the opportunity to realise value that much greater.
Fundamental to realising value to the system as whole (not just the health system) is the ability to realise value outside the NHS. Community services are well placed in that many of their services can be, and are, provided through the Third Sector, Local Authority provision and the Independent sector. While this might take resources away from the NHS, it may result in better value for the government, the taxpayer and the population as a whole. We must not be short-sighted or parochial in the pursuit of value.
Community services may be best placed to lead the way in radical service transformation, but others must follow. Cost pressures on the English health system will continue to tighten and demand will continue to grow. There is no quick fix to this. Changes in population lifestyle and wellness may be the Holy Grail for healthcare funding but these are societal and generational issues. That particular journey has barely even begun and will take decades to make even small progress in the impacts on healthcare provision.
The end goal must be to actually cease radical and ambitious change and operate in continuous improvement mode instead. This will require a different set of drivers, tools and behaviours. Whilst we would all desire to plan differently, most change still happens as a response to presenting factors rather than a desire to improve from an already performing state. Therefore, the majority of the time our rewards need to be urgent so the change is often constructed to be time critical, rather than change optimal. The solution is to get ahead in the change programme and make improvements to performing systems, not just failing systems. This is where continuous improvement begins to pay major dividends.
There is only so far you can go with ‘sticks without carrots’ and relying on the goodwill of any service under intense and continuous pressure to want to undergo painful step change and keep the service running as well. You also cannot expect the threat of a ‘Sword of Damocles’ i.e., closure of NHS organisations, to sustain continuous improvement over time. It might be a good incentive to kick start change but it must not be the only incentive.
The reasons for transformational change across the NHS are unequivocal and urgent. Effective support for those undergoing it remains today’s crucial challenge. It is a long journey, but one well worth taking.
February 2008
