Change won’t happen by accident

For the NHS as with public services generally, government has a limited range of levers at its disposal to create transformation and, in policy language, these levers together constitute a change model.

The mistake of recent years, undermining delivery of the Five Year Forward View and the integration agenda, has been the lack of a change model or – at least a failure to describe it.

Having a model and making it explicit means framing the debate, setting out boundaries and drawing on past lessons of what works and what does not – it would also counter the growing impression that the NHS is reactive rather than proactive when it comes to dealing with tectonic shifts like the tech revolution.

Most importantly, it will help the people we expect to drive the change on the frontline to better understand the motivations and reasons and increase chances of success.

Not having one means assembling public policy on the hoof, while keeping it from public view risks energetic but fruitless oscillation between neoliberal and socialist ideas without substance or insight.

Shaping a change model

When deciding how to shape the model, a good place to start is The UK Government’s Approach to Public Service Reform developed by the Cabinet Office in 2006.

It has since been condemned to the archives but the model has withstood the test of time and is more comprehensive than anything that has been developed since (and, declared interest, I was marginally involved in developing it and have continued to use if heavily).

The strength of the core framework – lovingly known as the “washing machine” – is its ideological and political neutrality.

It simply sets out the in principle levers and dimensions to affect change, of which there are four at the core: Top Down Performance Management (eg regulation, standards, targets), Users Shaping Services from Below (eg choice and voice), Market Incentives (eg competition, contestability), and Capability and Capacity (leadership, workforce, organisational development).

Having a model and making it explicit means framing the debate, setting out boundaries and drawing on past lessons of what works and what does not

In the NHS in the 2000s this meant: The internal market assumed a degree of competition or contestability will create incentives to outperform a single payer and provider model. The foundation trust model fostered organisational identity and autonomy and a degree of local competition to drive performance. The choose and book system was developed to create patient choice and drive performance bottom up. Waiting targets are used as a top down stick and rationing mechanism. National Institute for Health and Care Excellence regulation and standards ensured a level and transparent playing field for medicines.

In an argument that has become increasingly familiar in recent years as integration has become the prevailing policy intention, these levers are no longer appropriate. Instead they require organisations to give up power and behave like a system, most likely losing the provider and commissioner split.

Reworking the model to move towards integration

We now need to be more explicit about discontinuing previous policies rather than hoping for an organic transition – to stop layering the new on top of the old.

That means it is also the moment to decide and be more explicit about what range of levers, for a truly integrated system, will provide the incentives for continuous improvement.

For example, the most successful integrated systems all have a strong focus on outcomes – so I suggest this is a starting point. This in turn suggests putting more emphasis on patient choice and voice, especially in the absence of competition and organisational motivation.

Radical transparency combined with appropriate choice may drive wider benefits and pull innovation into the NHS. It may also help bind patients into their own care, if the outcomes are genuinely co-created and personalised.

Empowering patients to make better decisions should, therefore, not only be left to local systems, and currently does not receive the attention from the national policy agenda it deserves.

The success of change depends heavily on how we treat and involve the people running and using health and care services and their willingness to drive change

Learning since 2006 means two additional core dimensions should be added to the change model, and they are relevant for an integration agenda. First, behavioural science has developed rapidly and “nudging” has become an additional lever. Second, collaboration takes a far more central place in how we think about and understand change, but this is particularly hard in a system where most incentives point the other way.

We also now know a great deal about what has and hasn’t worked. Much of this story is about interdependencies between the levers – for example payment by results has been very effective in eliminating waiting times, but hampers collaboration.

We’ve learned about flaws in operationalisation – devolution to clinical commissioning groups was not supported by the necessary capability and capacity development, for example. There have also been failures in scale: patient choice is very limited, so is public engagement in foundation trusts. 

Crucially, the success of change depends heavily on how we treat and involve the people running and using health and care services and their willingness to drive change.

Change is more likely to happen and be sustained if they understand, feel and own the change – that underlines the need now for a move from change by accident to change with purpose.