Stevens’ nuanced view of change challenges cultural conventions

Leaders soon learn failure to close any gap between rhetoric and behaviour is the surest way to undermine credibility. Any new leader worth their salt should set out a vision, but have a plan to translate that into action as fast as possible.

“‘I’m neither here to command or cuddle you,” Mr Stevens might have said’

Just how pressing a requirement that is for NHS England chief executive Simon Stevens was clarified at last week’s NHS Confederation conference.

Disproportionate importance is attached to conference speeches by those giving, hearing and reporting on them. But Mr Steven’s address was seminal and the reaction was fascinating.

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He built a picture of rapidly developing new models of care driven by local choice, but underpinned by solid evidence.

Most who heard or read the speech commented on its intellectual rigour and ambition, but pressed further concerns emerged. Where were the clear “thou shall” or “shall nots” normally present in such speeches? Where were the reassurances the strength of the NHS would carry it through any change?

Scared and confused

“What am I meant to do with this?” was the murmur behind the applause. To which Mr Stevens would no doubt reply, “Think about it and make the appropriate plans.” Perhaps adding: “I’m neither here to command or cuddle you.”

But it is here Mr Stevens’ powerful technocratic vision runs into the NHS’s two default cultural settings.

‘Stevens faces an internal challenge: how to get an NHS England team schooled at SHAs and PCTs to adopt a new way of working’

The first is to take orders: seeking clear instructions from the top, often complaining, but normally complying. The second setting – beloved of politicians – is to be told that almost all wisdom lies at the front line and any involvement of the centre should the absolute minimum as local decisions become sacrosanct.

Mr Stevens offers a much more nuanced view of the health service: one in which the centre is responsible for helping develop a deliberately limited range of evidence based options, which local organisations then take the responsibility to mix and match in order to determine the most relevant local solution.

This scares and confuses a lot of people: many of whom work directly for NHS England. The organisation built by its first chief executive Sir David Nicholson was one happiest exerting grip or cheerleading for clinical commissioning groups – two apparently mutually exclusive modes of operation which, of course, reinforced the default culture settings.

Culture challenge

No wonder then that a febrile mood predominates in NHS England – with non-executive directors seizing their chance to shake things up, while directors and senior managers try to work what the new bosses’ approach means for them and their roles.

Mr Stevens knows he has to shift the centre of gravity of his organisation to a place better able to realise his vision, but he also knows he must move carefully. NHS England’s “grip” on the service is as “illusory” as that exercised by most central bodies – but send the wrong signals that freedom now reigns and the result could be “chaotic”. Clamp down too fiercely on the sometimes questionable choices made by CCGs and it will be “meet the new boss, same as the old boss.”

Already the “new boss” is on the lookout for decisions that are symbolic as well as substantive. The seemingly endless flow of “guidance” to the service is already being better managed. Key decisions, like the NHS England view on the potentially era defining Manchester reconfiguration, are beginning to line up.

But Mr Stevens also faces an internal challenge: how to get an NHS England team schooled at strategic health authorities and primary care trusts to adopt a new way of working. He needs an organisation more comfortable with risk and uncertainty; more willing to challenge convention; but also to let others take the lead. That cultural challenge may equal any he faces.