David Dalton: Culture change takes commitment from all tiers of an organisation

My two recent visits to south west London’s Elective Orthopaedic Centre and Hinchingbrooke Health Care Trust provided a great opportunity to learn more about two ways of delivering NHS care.

This has provided me with a chance to reflect on what very different models of service have to offer the NHS, and how they are overcoming some of the barriers that have faced them.

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Single service standardisation

The centre is a joint venture between four south west London acute trusts: Croydon Health Services, Epsom and St Helier University Hospitals, Kingston Hospital Foundation, and St. George’s Healthcare.

Established in 2004 to deliver strategic change in orthopaedic care, including inpatient, day case and outpatient, it is the largest joint replacement centre in the UK. It is also one of the largest shoulder surgery centres in the UK.  

‘The benefits of standardisation have come to the fore’

They have done some fantastic work in standardising the way patients are cared for, which is greatly improving outcomes.

A clear focus on a single service with a limited number of service lines has allowed benefits of standardisation to come to the fore.

The ability to standardise the patient pathway, operating procedures and the procurement of products has enabled reliably high standards of care and outcomes to be achieved at a productivity level that ensures financial viability. 

Senior clinical engagement with management practices has been achieved. These strong relationships are also enabling high quality research and audit.

The franchise solution

Hinchingbrooke is operating a different model. In November 2011 it became the second NHS hospital to be franchised, with a 10-year contract awarded to private provider Circle.

Circle took on a trust with significant financial and clinical challenges. It has made improvements to both, recently winning an award for top quality patient care.

The two are substantially different in a number of ways, notably the scale of the model, and the number and types of organisations involved.

But they faced similar barriers when establishing their models and are both looking to build upon and embed their successes in similar ways.

The culture challenge

It is often said that the biggest barrier to bringing one or more organisations together is the different workplace cultures among staff.  

Different teams and organisations have their own ways of working; they may be equally high performing when independent, but to maintain and build on this there needs to be a shared culture in the new organisation or team.

This can be the hardest thing to get right in organisational change. However well planned and structured, the ultimate configuration is that it will not operate effectively without shared culture and ambition. 

Hinchingbrooke has a high level of staff engagement through Circle’s “mutual” approach, where staff are entitled to join the share scheme.

‘Staff felt the power to make change had been put back in their hands’

The staff spoke of feeling that they are now motivated to find the solutions to their problems and that their ideas, previously quashed through layers of bureaucracy, are encouraged and acted upon. 

They have a lean management structure, with an executive board of 15 members of which the majority are clinicians leading clinical divisions. 

The staff I spoke to said that they feel the power to make change has been put back in their hands. They feel safe to innovate and safe to hold their hands up when things have not quite gone to plan. 

One consultant spoke of the sense of achievement she felt from moving chemotherapy into patients’ homes, when previously she had been told by management that it could not be done.

Removing the barriers

Establishing this culture takes effort and commitment from all tiers of the organisation, but doing so has led to some fantastic service performance, driven from the bottom up and with managerial buy-in.

These two visits have made it apparent to me that there is a huge desire in the sector to innovate, share best practice and look beyond traditional structures to provide the best possible care for patients. But this is not always easy.

‘Establishing this culture takes effort and commitment from all tiers of the organisation’

Along with the issue of workplace culture, there are often regulatory and legal barriers to innovation and entrepreneurial thinking. We need to do more to remove these barriers - more on this later.

I am really pleased to have this opportunity to give the message to government and NHS leaders that we must enable organisations pursuing success to do more, and to offer real solutions to those facing significant operational challenges.

I am looking forward to further visits and discussions with staff, patients and sector leaders to inform and shape my recommendations.

You can feed into the review, email the review team or contact them via Twitter #DaltonReview2014.

David Dalton is chief executive of Salford Royal Foundation Trust