The Mechanics and Morality of Change in the NHS.

In this new year of 2024 (an election year), I, like most people, believe this will be a significant year for change in both the NHS and other public services.

So over the next few weeks I plan to talk about not only what changes I think we need, but also the detail of how we bring them about.

My final pre-Christmas post argued that too many people feel that the current way of working in the NHS and public services is the only way of delivering services. I suggested that much more change was possible. And over the next few weeks I will describe how we all might go about doing that.

This will require transforming the process of making of big changes into normal everyday behaviour. To reiterate a point I often make, there are a million NHS consultations every 24 hours. Add social care to that and you get close to 2 million consultations every single day. If we are to help health and social care better improve the health of the nation, most of those consultations will have to change over the next decade.

Change on this scale must move beyond being the hobby of a few people to being the drive and work of us all.

I am sure others will want to add and subtract from my list, but for every change we will need to be cognisant of at least six themes that will influence how you bring them about.

1  First, any change in clinical practice means that many staff and patients will have to radically alter the way in which they work or receive care. Often many of these changes will go against the way in which staff and patients believe care should be delivered.

When arguing for change, one should never expect staff to simply say “Well this new way of working is obviously better. Let’s crack on with this change!”’ A very few may, but most won’t. If you want real change don’t assume that just because you have got a new ‘policy’ through your board – or even through NHSE – that staff will change the way they work.  And please remember that the fact they don’t welcome change does not make them bad people or bad clinicians. If you want people to undertake the hard work of change you must first empathise with them if and when they find that change difficult. For some of us, when we are arguing for the importance of change, the hesitancy of others is just puzzling. Our belief in the importance of the change makes us want to sweep aside any opposition and just tell evryone to “get on with it”.

This approach doesn’t work. The long history of command-and-control management in the NHS has led people to believe that change can be achieved by instruction. It can’t. The dirty secret of the NHS command-and-control management style is that it is all command and no control. To bring about change you need first to understand why people want to hang on to their current ways of working. Within that motivation you may find some parts of your argument for change. But, above all, if you want to succeed in making change – empathise, empathise, empathise with the people who don’t want to.

2. It is essential to develop an overarching narrative which demonstrates how the change you want will create better outcomes for the public. Change is NOT just a technical issue. I talk about ‘winning people’ over to change through argument. This argument will have many forms but some of it must demonstrate a better life for the public. Always, when arguing for change, bring patients into the room. Make sure they are always there as a part of that argument.

3. Make sure you have, from the very beginning, a plan for how you are going to expand change. Back to the nearly 2 million consultations every 24 hours. The NHS and social care needs change on a very large scale. Even if you are at the very top (or have backing from the very top) no-one up there can tell the 2 million people working in health and social care (let alone the public) that from next Tuesday they have to work differently. (Or more accurately they can tell them but don’t expect 2 million people to do what they are told). From the beginning think through how you will grow your change from the very small (acorn) to being a bit bigger (sapling) and how you will spread the work through the whole of practice (tree) until it becomes ‘routine’.
The NHS is very bad at this so you may need to look outside it for tips on how to do it.

4. The financial structure within which you work has been created to bolster the very practices and processes that you are trying to change. You will need to develop new aspects of the financial system to incentivise your changes.

It’s true that there are a wide range of incentives for NHS and social care staff and organisations to work in a certain way and finances are only one of those incentives. But if you want to move a new form of working into the mainstream you will need to ensure it stops being a hobby and becomes a part of the work people and organisations are being paid to do.

For example, since 2006 the NHS has had a series of policy papers arguing for much better integration of NHS and social care services. The fact that current financial systems continue to fragment care has been more significant in maintaining that fragmentation than all the policy papers arguing for integration.

5. Most new ways of working claim they will save money. If yours does, in a modern NHS, it will only succeed if you pay enough attention to making sure that money is actually saved.

Nearly every commentator looking at the future of the whole care system argues that money needs to be shifted from one part of the system (say x) to another (say y). For y to gain new investment then the saving of the money in x needs to stop being pretendy and must become real. Many of the arguments for introducing most new services in social care and the NHS contain the idea of a return on investment (ROI). Unfortunately, it normally remains at the level of an idea. Change in the next decade must be based on ROI being realised (make it real) – otherwise the change will fail.

6. The NHS and wider public services are a very complex system. Even if the change you are arguing for is a small one it will have wider implications. For your change to take root and thrive you will need to understand how it interacts with that wider complex adaptive system. First recognise that whilst this may be a very good idea – which you think is brilliant – for some others in another part of the system it may cause problems. Many people – experts at change – have remarked “that everything is connected to everything else”. Whilst you may want to say, “my change is only a little self-contained thing” It won’t be. You need to think through what the much wider implications are. That doesn’t mean you shouldn’t bring about the change, but it does mean, if you want to be successful, that you will need to take those wider implications into account.

Later this week I’ll discuss an important example of change that has justifiably received a lot of media attention.

From next week on I will start running through, once a fortnight, a series of WHAT changes and work through these 6 “how” arguments for each of them.

Let’s hope that after a few examples it doesn’t become so obvious as to be boring – (Or conversely that it does, and so becomes normal).