Walking the tightrope – balancing immediate change and long-term improvement in the NHS

Leaders of NHS Trusts face huge pressures to provide sustainable, high quality care for their local populations. They must manage growing demand, an ageing population and constitutional performance commitments within challenging budgets. It is no surprise Trusts are struggling to find the balance with many being put in ‘special measures’ by the Trust Development Authority (TDA) or Monitor for serious failings in care and concerns that leaders are unable to drive the necessary change.

Managing all of these short-term pressures against a backdrop of changing political priorities and government initiatives is difficult. Doing so in a way that is sustainable for the future without simply fire-fighting today’s challenge seems close to impossible.

So how can a leader walk this tightrope?

Trusts must consider change holistically, rather than as multiple quick fixes. Behaviours and motivations across the organisation must drive towards long-run strategic improvement, aligning the Trust from “Ward to Board”. This can be done through:

  1. Engaging individuals honestly and openly in the Trust’s strategic journey;
  2. Implementing a ‘firebreak’ within Trusts;
  3. Taking a whole-organisation view and removing false divisions and silos.

1. Engaging individuals honestly and openly in the Trust's strategic journey

Visible leadership and clear communications channels from “Ward to Board” should be available. Each organisation must have its own forums for engaging both middle managers and front-line staff. However, the crucial factor is not what mediums are in place, but that this is done as a dialogue with staff, focused on an open assessment of the root causes of the challenges faced. After all, it is often those at the coalface who have the best understanding of how positive change can be made.

Each organisation must have its own forums for engaging both middle managers and front-line staff

Too often, staff engagement becomes either a top-down enforced activity, or a bottom-up complaints process for raising problems. Success is not about one individual or team absolving themselves of responsibility but rather allowing direct engagement to open up opportunities to do things differently and make real and effective change.

Honest engagement also includes working with external organisations to establish a joint commitment to do what is collectively needed. The Trust is often where the symptoms of others’ shortcomings are seen, and those other organisations need to see themselves as partners in improvement. Examples of this include the role of social care in reducing both avoidable attendances – such as residents from local care homes – and Delayed Transfers of Care that often result from care packages not being made available.

2. Implementing a 'fire break' within Trusts

Engineers and architects design skyscrapers to contain and compartmentalise fires, limit the spread of fires and allow the fire to burn out without the building collapsing. This principle could be applied to Trusts. Trusts should isolate their problem areas and implement a ‘fire break’. By focusing on the one or two root cause issues that really matter, rather than trying to clear a backlog of hundreds of priority changes, they will protect the organisation from ‘too much change’. This can only be done if there are clear targets, with a robust understanding of the data to identify the highest value interventions.

3. Taking a whole-organisation view and removing false divisions and silos

The two points above point to an organisation-wide approach to improvement. At the heart of this is the need to bring everyone along the same journey, empower them to take responsibility for contributing and providing the evidence and tools to support that improvement. The focus for leaders must therefore be to break-down silos or sub-cultures that may undermine this collective improvement mind set. Being true to this requires leaders to be firm, and to be prepared to take decisive action to preserve a single ethos and shared culture of improvement. This has to be led from the top.

The journey to sustainable improvement is not easy against a backdrop of political pressures, systemic failings and budgetary constraints. But success can be achieved if you align top-down and bottom-up leadership and combine “hard” and “soft” approaches to engagement, information and culture.

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Leila Callaghan Client Director