Health and Social Care Leadership, Organisational Design

Where does the future of the NHS lie – competition or collaboration?

Ever since the first purchaser/ provider split in the 1990s, patients and the NHS have been told that competition is the best way to drive up quality.  This has led to different systems over the years such as payment by results (the tariff based funding system) that have created incentives resulting in providers often competing with each other to provide patient care. All with the aim of driving up quality to attract more patients.  So far, so logical.

These principles worked to a degree when the problem was long waiting times (although arguably to the detriment of those services still on block contracts such as mental health and community); however the problem has changed.

Today demand has increased due to the advances in modern healthcare helping people live longer and survive premature birth and severe illness where previously this was sadly not the case.  This is at a time when social care has seen unprecedented reductions in funding, with 900,000 fewer people in receipt of social care than 2010 coupled with funding in the NHS not keeping pace with demand.

Patients have more complex needs due to chronic long term conditions and co-morbidity and so the logical solution can no longer be applied.  A more sophisticated funding mechanism that can cope with complexity is required.

In today’s world it is clear the pseudo-market economy logic and mechanism no longer works.  It’s yesterday’s solution.  Too often patients fall through the cracks of bureaucratic systems; clinicians are forced to find workarounds every day and managers are trying to make a square peg fit into a round hole so to balance the triumvirate of finance; quality and safety.

Another policy to cement competition was the creation of businesses or Foundation Trusts.  When this idea was first conceived in around 2004, the aim was to establish them as public benefit corporations.  Although a great idea in principle, Foundation Trusts ended up becoming legal business entities meaning that not only did they fall under the Enterprises Act 2002 and become subject to competition law but legally the first duty of the Board is to the organisation.  Great for competition, potentially not so great for creating a cohesive health and care system.

It is feasible that if health and care organisations had a first duty to their population, as a public benefit corporation suggests, then collaboration would not only be far simpler, but absolutely essential to deliver the right level of care to the population served.

All in all, it seems the competitive approach has served its purpose and now we need to move to a new world which sews back together fraying seams and in some cases, great gaping holes of the health and care system.  The needle we need to use is collaboration.

Sustainability and Transformation Plans (STPs) are going some way to address this conundrum and could start to pave the way for much greater collaboration if the incentives are aligned and executives are not forced to put their own organisations before the benefit of the wider STP.  It is crucial that the STPs give the proper time and attention to building the relationships and designing the clinical models that will become the bedrock of the new health and care system.  Tempting as it is, rushing into a new organisational form before this work has been thought through could actually worsen the situation.

In a previous blog post in 2015 I explored whether or not organisational form was seen as the silver bullet for the NHS.  It is dangerous to underestimate the impact of a restructure as often an organisation’s value is found in the informal structures created through internal relationships, shared history and the stories that are retold within the organisation, rather than the formal structures.  The risk becomes that in creating something new, the value is unwittingly destroyed.

Form follows function and therefore it is crucial to spend time creating shared purpose, building partnerships and strong relationships both at the top of organisations and also through bringing clinical teams together to ensure the clinical models are right.  The final step is to design the right organisational form to wrap around these new arrangements to cement in the new ways of working.  In this way we will find new organisational forms that are better able to solve the complex issues emerging today.

In order to ensure the NHS can not only survive this decade but thrive in the next decade of its existence, we need to find a way to manage the complexity in which we find ourselves in.  The only way to do this is through seeing the system as a whole and starting to form the relationships we need to design not only new ways of delivering care supported by new structures that make it easy to do the right thing, but most importantly, we need to find new ways of being so we can change things for the better.

As the old African proverb says; if you want to go fast, go alone. If you want to go far, go together.
Guy’s & St Thomas’ partnership statute outside St Thomas’ hospital 

About the author
Sarah Morgan is the Director of Organisational Development and the Programme Director for the Acute Care Collaboration Vanguard Programme (developing one of the first hospital Groups in the NHS) for Guy’s and St Thomas’ NHS Foundation Trust.

Sarah was previously the Head of the Dalton Review which examined organisational form options for providers in the NHS


Are we mindfully leading or just minding the gap?

My blog has been a bit quiet in recent weeks due to two reasons. The first being the night I posted my last blog, we got burgled and they stole both my personal and my work laptop. Secondly, I’ve have the privilege over the last six months to lead a national review into options and opportunities for providers of NHS care – or the Dalton Review for shorthand – which in recent weeks has eaten into my brain capacity and time somewhat. If you’re interested in reading further here’s the link

This lack of time and capacity to actually write my blog and do other things that I love to do, such as exercise, got me thinking about how this lack of time affects our ability to do our jobs well and our ability to lead effectively.

When I was University and directly afterwards, I got interested in meditation and Buddhism and the art of just being still. I spent time living and working in New Zealand and became a trained as a Reiki practitioner. When I returned to the UK, I joined the NHS graduate training scheme and although I remained a member of the UK Reiki Federation for many years, the relentlessness of operational management meant I spent less and less time thinking about meditation and making time to be still. In fact being still is the antithesis of what it means to be working in frontline services in the NHS.

Mindfulness is being thought about and discussed more and more as a leadership tool and during the work I did on the Dalton Review, we looked into the characteristics of High Reliability Organisations. These are organisations that consider safety paramount such as the aviation industry and in North America, healthcare, and there are certain characteristics, one of which is mindful leadership. This started me thinking about the NHS and the experience I had before I joined and fire-fighting got in the way.

High reliability organisation characteristics

Image from High Reliability Organisations – A literature review, Health and Safety Executive, 2011)

Mindful leadership pays attention to what matters. Jon Kabatt-Zinn who has been the guru on mindfulness for over 40 years, describes it as ‘paying attention in a particular way: on purpose, in the present moment and non-judgementally’. This is a pretty tough ask for today’s NHS.

The NHS deficit is outstripping its surplus this year for the first time and includes a larger number of trusts predicting a deficit. The National Audit Office report into the financial sustainability of the NHS published in November makes gloomy reading There was welcome news in the Autumn Statement with George Osborne announcing an additional £2bn funding for the NHS. Whilst the full £2bn may not all be ‘new money’, there is a welcome £200m for transformation and taking forward the clinical models outlined in the NHS Five Year Forward View Although the cash injection goes someway to help, it does feel as though the majority of our NHS leaders are minding the (financial) gap rather than being enable to lead mindfully, paying attention to what matters.

So how do our NHS leaders move from minding the gap to mindful leadership?

An article by Erica Garms on practicing mindful leadership points to the fact that effective leadership requires, “self-knowledge, self-awareness and centredness and an ability to manage the constant onslaught of inputs and stimuli and maintain good brain health so that clarity of decision-making can prevail.”

So how do we achieve this when we are running from crisis to crisis and meeting to meeting?

Answer – Meditation

So back to my days at University, practicing meditation – which doesn’t necessarily need to involve sitting in the lotus position, in a dark room chanting ‘Om’ – but rather, just taking a few precious moments to centre yourself, concentrate on the breath and calm your mind. Erica Garms points to examples such as doing a ‘body scan’ sitting in traffic or just taking the time from walking from one meeting to another to calm the mind and take a minute. I find staring at the clouds moving in the sky often helps to clear the mind.

Building this into daily life and work has proven to help many managers become much more effective. The problem is that’s not how we are wired in the NHS. Fire-fighting and solving problems is our modus operandi and stopping to think is really not part of our psyche.

So how do our leaders make the time to pay attention to what matters and to not just mind the ever widening gap in the NHS finances? In fact, paying attention may help to close the gap.

This will be down to individual leaders deciding what is important and taking the time to take a moment to really think about what they need to pay attention to. As I’ve blogged about before, the skills that we will need for the future leadership challenge are different to those that we have today

My personal view is that leadership in the NHS needs to become much more strategic and regularly plan for the medium to long term. The political environment will always be uncertain and ambiguous but the idea that this leads to only being able to plan on the short term is a false one. Good leadership is about determining the long term vision for the organisation and focussing on that. Adapting this strategy and being agile to the changing environment is part of the planning process. Horizon scanning and scenario planning to test what would happen if certain changes came into play is good strategy development and should be integral to the process.

Leaders taking time to think and to pay attention to what matters and really consider the options should be the priority. These skills will take time to develop, but if the research is correct, will lead to better patient experience, better staff engagement and a brighter future for the NHS.