Roundtable Discussion: Sustainable Change within the NHS

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Date: Thursday 9^th May 2019

Venue:  Holborn Bars, Chancery Lane, London

The purpose of this roundtable discussion was to ask senior NHS leaders, including COOs, CFOs, CEO’s and Turnaround Directors their thoughts and innovative suggestions on how we can deliver and maintain sustainable change within the healthcare sector.

The main areas that came up in the discussion were:

• Clinical Engagement and how imperative this is

• Setting the task parameters and programmes with clear but more limited remits deliver better than those with dozens of goals

• Managerial change and responsibility

• Technology of change and future proofing

• Realistic time frames for sustainable change

CHAIR’S INTRODUCTION

 “We have all been trying to implement sustainable change to our own organisations. But if you’re going to get sustainable change, you have to ultimately get buy in from stakeholders. Personally, I think sustainable change is all about leadership, building trust and looking at these different behaviours. Yet within this, organisations still must meet their targets, budgets and quality of care for patients. How do you achieve that?”

MANAGERIAL CHANGE AND RESPONSIBILITY

An increasing number of organisations are under immense pressure to meet performance targets, and all while keeping to a tight budget often whilst in a deficit situation. Collaboration between departments and organisations is critical as it helps staff to see the bigger picture

• “Targets are there for a reason, but do they work? Performance is always being measured and managers are increasingly under pressure, when you’re doing 85% and not 96% that responsibility ultimately lies with you – you are responsible despite many factors. The question is are the performance targets actually the correct measure of success?”

• “You have to gain buy in from everyone, the work I did safeguarding adults encouraged different organisations to come together as one unit, it’s about breaking down organisation barriers to change. You need one collected vision and I think this is something the NHS should take on board as it is so important we collaborate. It’s a common purpose and common sense but trusts are bad at seeing the bigger picture.”

• “I worked with a Trust and the leadership team were not engaged, they were tokenisticly engaged, this shows that there is no real interest in change, it’s just a box to tick hence change simply didn’t occur and there was no sustainability.”

CLINICAL LEADERSHIP

Some trusts adopt the ‘inverted triangle’ approach within their staffing to encourage engagement and to inspire them to make small changes from the bottom up. Our experts discussed how this model should be explored further.

• “When talking about sustainability you’re talking about permanence, how long does it remain? You must have the mechanism for maintaining change and those two approaches are: ‘Hearts and Minds’ and ‘Continuous Improvement’ these work best together not in isolation and the clinical engagement and leadership elements are key factors.

• “If you look at successful trusts, they all have a good improvement methodology in place. They are the bottom up social movements, you are creating change and it empowers front line staff to make the change then it is more likely to happen. Every time I’ve seen a lack of clinical leadership it’s because there hasn’t been that engagement, you try and repeatedly implement change methods and it will fail without engagement of the clinical / front line teams, but it does work if you have the right buy in from your staff.”

• “It’s about working as a team, and the ‘janitor at NASA’ idea applies to this! e.g. the janitor working at NASA helps astronauts walk on the moon, he’s a vital part of this just like everyone else in the company and this is the approach the NHS needs to adopt.”

• “It starts off with the front-line staff. If we use continuous improvement as an example, they’re given ownership of the processes they operate, you have this inverted triangle so that they make the changes and it gains momentum from there.”

• “Not all Trusts deal with inverted triangles as it is a loss of power to let your junior staff lead, this is where it enters a political agenda and becomes even more complicated”

• “Hearts and Minds works the same way, the common denominator must be people led, not all trusts/boards are good at implementing the inverted triangle as they lose ownership (perceived power) but in two trusts that I have worked in, this has always worked well. It has to be people orientated as a starting point.”

• “What the NHS don’t do well is attract the best people to the most challenged trusts as it mainly because the best people are often more worried about the risk to their reputation. What we need to do is support them and let these people inspire the front-line staff to go and make things happen and support them with a difficult journey. We don’t do that. The talent is there but the politics are blurring the lines between fact and fiction.”

IS THERE AN END POINT TO SUSTAINABLE CHANGE?

Change is all very well but is there actually an end point? Should trusts be looking at more realistic time frames for achieving change?

• “The reality is we need to be able to change and change well, but not think we’re ever going to reach that golden steady state. It’s that very thought process which disempowers staff, because they think I’m going to change this one thing and then that’s job done – isn’t it the very nature of the NHS that change is the one constant.”

• “Define sustainable? The period of time to achieve change is important, 10 years yes but why not 5 years or even 2 years, is that sustainable? It’s better to think in short periods because then it’s more realistic and achievable. Are we dealing with ‘change’ or ‘transformation’- does everyone truly understand the difference?”

• “I agree, change is continuous, so we need to accept and embrace it we won’t reach the end of change but should instead manage it in a way that delivers stable sustainable change in a realistic timeframe with defined goals.”

TECHNOLOGY AS AN ENABLER

When discussing what enablers might help achieve sustainable change, our experts expressed their thoughts on how technology could be a contributing factor and how we need to future proof our practices.

• “If we’re going to achieve sustainable change, in my opinion, it will be based on the change and advance of technology. That’s what I’d be looking for, what’s the new technology that will shift things?”

• “Yes, it’s about the people who deliver not simply the technology they use that’s why it’s not sustainable. In every trust, every CCG, it’s all the same; as people leave their position, the cooperate memory and legacy information leaves with them and their work can’t be continued so they start over again and repeat the cycle.”

• “I was at NHS direct in 2010 when the pandemic flu hit us, in my opinion that’s the only reason the NHS went onto the web-based support because of the sudden demand that was being made on the system. It was an immediate response to a difficult time that drove a tech advance that I hadn’t seen before. We were taking good evidence-based pathways recorded data and putting them onto a technology base that was not fully understood or adopted by everybody to the same degree.”

• “If we’re going to build on integrated care we need to future proof it, we need to future proof our working practices. In our 2009 ‘10-year plan’, we didn’t think apps and smart phones would be so integral to our day to day lives but look where we are now. By the time we get to a new point of sustainable change, we’re already at the next step of technological change, so how do we manage this – shorter planning periods?”

• “I think technology is important, but I think it’s more about the leadership that supports it. Everyone needs to work towards a common goal and technology can help this. But I’m looking at this from a nursing point of view and I must emphasise that there are more concepts than tools to allow technology as an enabler it cannot be a stand-alone solution.”

PROCESSES AND SKILLSET

How do you implement change? Our leaders discuss the importance of ensuring the action sticks and that the proper skillset has been adhered to.

• “The big issue that I find is there is often and intervention to deliver improvement and this works whilst there is constant focus but after a while once the focus moves in most cases everything goes back to pretty much how it was originally before the intervention. If I was to summarise why this happens, the issue is the skillset that’s required to make a change happen, this is often led but then not embedded in order to make it sustainable with local teams taking ownership.”

• “Teams become jaded to change so the next time a significant change agenda happens, you try to turn the handle on the same process and it simple won’t deliver the result it did last time. You need the human intervention, the intelligence, to say this is a set of issues I’m facing, how do I respond to it? Now this starts with the leadership at all levels, it’s not about technical skillset as you can buy that it’s about a shared willingness to improve and change.”

Thank you to everyone that attended this roundtable discussion. If you would like more details, including an anonymised transcript, please contact emma.whiteley@practicus.com