Health and Social Care, why is transformation taking so long?

John Mortimer

Having just got back from a public sector conference, looking over the day and asking myself the question as to whether or not these gatherings help? The answer is yes, many people discussed good things that teams are doing, and agreeing what we should be doing. But one phrase from the conference really did trouble me; 

‘We now know what we need to do to make Transformation work’

And then someone reminded me of something. They showed me a report with this great list of innovative health & social care working principles:

• Holistic approaches and co-production
• Devolved responsibility for decisions about resources to local level with real accountability to families and communities 
• Community work, engaging with the strengths and talents in the neighbourhood and nurturing local voluntary organisations and associations – “helping communities be strong and resourceful”
• Undertaking local social care planning on an inclusive basis

Now imagine the The Health Minister agreeing the above and stating in Parliament;

The theme of the plan is to harness the efforts of the community in both the statutory and voluntary sense. That is very much in line with the Government's view.

Well, this list and this quote is from the Secretary of State for Social Services in 1982! The realisation that dawned on me that we have been there before, and we’ve revisited this several times in the last decades, was a jolt.

Does anyone reading this recognise that those wanting the job to transform health & social care, where after several decades, realise that their work has made no meaningful impact? They all seem to be doing good work, but with almost no real lasting difference.

We try and make improvements, but what about those who work there? What can it be like for them? Imagine that when an NHS nurse gets to work starting their shift, that their manager slaps them in the face, then later on the manager sticks a pin in their leg, so it bleeds. Then at lunchtime, the manager hits the nurse over the head and causes a headache. What would we think of the behaviour of that manager? 

Obviously this account is ridiculous and would never be acceptable. But if so, then why do we accept this behaviour when the abuse does not lead to any obvious physical damage? We encourage nurses and social workers to train, and encourage them to accept low pay with the promise of having a job that really matters. And then, when they start the job, we ensure they can never do a job as they were trained to do, because there is not enough time. And we command them to stop using their brain and follow simple and stupefying instructions, so that they cannot really help the patient in the promised way. And we treat them to the point where they often cry with frustration on their drive home. How have we come to accept this abuse?

This mindset that we have developed leads to ridiculous accepted conclusions; 

1. What is one of the problems of the NHS? We don’t have enough nurses. 

The root cause of the symptom of not enough nurses is that the nurses we train, start work, get abused by the NHS system, and leave. We have always had plenty of nurses being trained, we simply throw the opportunity away, and damage careers in the meantime. Can it be morally right to convince, train and then give someone a job that is not possible to be morally fulfilled? 

Taking the same situation but with a plasterer who plasters the walls of old properties, the result of this situation for the plasterer would be a poorly and partially plastered wall. Would anyone simply accept that? Imagine thousands of new houses with partially plastered walls, is a ridiculous outcome to contemplate. But why do we accept this in our public services? Is it because plastering is physical that we can see it so obviously?

Management of Public Services

Managers in the public sector are not one homogeneous mass, but they do seem to behave in a similar way. Whether managing nurses, council officers or road repairs, their answer in a situation where a member of staff cannot complete the task given to them for that day is in many cases a shrug of the shoulders. The one time that a manager has to use their ability to lead and manage operations, they abstain in the worst possible way. 

Managers are paid more, and part of their role is to manage and maintain the operations and delivery of services funded by the public for the public. One hundred years ago the Suffragettes managed to get 50,000 people to march to London; before phones and the internet. They were showing the world that the situation had got to the point that it desperately needed to change. What should our leaders in the public services be doing to highlight an impossible and abusive situation? Certainly not simply shrugging their shoulders - why can't they sit on the steps of Whitehall for a day in demonstration. NHS leaders are somehow subservient to their hierarchical masters, but surely their job is also to push upwards to their bosses? Public sector leaders have a duty to highlight and ensure critical aspects of the organisation, not simply to act as top down mouthpieces. The Windrush issue is an example of managers having to follow and not react to bad culture.

Lastly, what of the impact on the most important group of all - those the services are helping - Us, the public? This could be the subject of another article - but what of those millions of interactions since 1982, that could so easily have different outcomes.

At times, managers can and do get dismissed from their job because they say something that is overheard, published and deemed racist or suchlike. But when managers ignore and take advantage of their staff, there is no public outcry - they carry on with their job. Are a few misplaced comments far more important than peoples livelihoods?

The Cause of the Problem

Enough wringing of hands, and bemoaning the lack of political will. Moving past despondency and looking for hope, lets look for the systemic cause of the problem. Why after 35 years can we not implement real transformation? For me, the answer emerges surprisingly quickly and clearly.

Those who Govern the System

Elected politicians, MPs, on election day are suddenly pushed behind a desk and have to run the public sector. They have to oversee a hugely complex and large organisation. Would they know if Universal Credit is a good idea? You can ask this question to people whose job it is to deliver benefits and half will say yes, and the other half say no. It is a complex issue that can only be answered by understanding the whole system, and how people truly interact with it - understanding it as a real behavioural set of individual workflows. Imagine MPs attempting to make clear judgements in the middle of the myriad of conflicting pressures that they face daily. Its not heir fault, its the situation they find themselves in - needing to make policy decisions before the next minister arrives.

The Structure

The direct imposition of short term political decision-making on the long term nature of public service is an ill-matched structure of control or governance. Politics is an emotional and illogical maelstrom of ideology and decision making, and these characteristics are the opposite of the characteristics required by the structural nature and purpose of the public sector services we expect politicians to be able to oversee. We watch as expectant policies are kept out of the meandering reach of decision-makers; lost opportunities for key decisions, indecision, and fear of election consequences - demonstrating clearly that those decisions that are needed are simply too large and complex for the political environment at that time. MPs or councillors do not control public services, but they do create the environment and governance by which those services operate. A good example of this is how the imposition of austerity has driven the public sector recently. Also, central government has an important task in defining elements of the wider system - like management competence, digitalisation, etc.

So, if it is so difficult to know what to do in the face of a barrage of conflicting information, it is the height of irrationality to expect MPs and the collection of those who report to them, to effectively oversee such complexity. And no, the Civil Service cannot do it either - they are good at bureaucracy and administration and maintaining control, not managing complexity.

If this was a large private sector multi-national, the CEO would put in plans to change the structure and replace leaders with ones that have the correct competence. It could be completed in six months. There is no practical reason why this cannot start to happen in the public sector, if the will was there. And it would free up politicians to do the job that they are good at doing - from a distance.

It seems Incredibly Difficult to Achieve

When I work with managers they are quick to explain the a number of reasons as to why a particular change cannot happen. It is the nature of the culture that we see that the public sector is full of barriers to moving forward. However, when working with certain senior managers it can be demonstrated, and to their great surprise, that these barriers can be overcome. When working with teams to develop new approaches, there always comes a time when making forward progress, the team realise that they have broken the public sector spell of continually struggling in decision quicksand. From that point forward, the team move into a new decision-making paradigm, and we move into new territory of true change.

What is the Root Cause?

We actually know how to run public services well, there are islands of examples using innovative methods that have demonstrated a transformation from the old style public sector administrative master-servant relationship. We have seen that services can be transformed so people in need can be guided to get their lives back on track, and communities can rediscover their strength. Many times these fledgeling examples are caught up in larger pressures, that then throttle their existence; they need to have the appropriate underlying long term alignment across the public sector to continue and thrive to other areas.

Most of the truly transformative change I have been a part of has reverted back to 'normality' due in all cases to new managers taking over the service, and bringing their old management style and behaviour with them.

What is a Solution?

There are people who know how to understand, and then manage operational complexity. And there are also clever people who can make things happen. Find those with both attributes, and put them in a room together, that also spans a cross-party political landscape - ideology has to take a back seat here. That group then leads that part of the public sector - they decide the structure, what methodologies are most valid based on evidence, manage transformation through proven prototypes, and ensure the appropriate leadership competence is promulgated throughout the sector. So that the transformation can emerge to all parts of the sector. 

Their strategic vision will span 25 years. They could plan for changes in technology and demand, tackling preventative longer term solutions to impact on problematic root causes. And their appointment to the group is neither as elected officials or private sector capitalists. They would be a unique group whose selection has to be decided with caution and transparency.

An Example

Using the example of the problem of ‘not enough nurses,’ that group could ensure that nurses are able to do their job by ensuring a minimum number of nurses in given situations, and that the nurses are treated with a level of management attention and approach that is now expected in any other industry. They would define management competence and ensure management suitability to those competencies. Most importantly, they would understand the core journeys service users take through the NHS, and they would ensure the structure and services are designed to match those user journeys.

Political (public) oversight must still be in place, with the ability to ensure that the public leadership group is doing the right job.

So is the systemic answer is that we need a different governance structure?