NHS Providers and Systems – improving organisation performance & health.
Michael Shaw
Transformation & Cost Improvement Delivery Consultant | Programme Director | Public Sector | NHS | ICS | ICB | Acute care | Community care | Primary care | Mental Health | NHSE | Not for profit
I recently posted reflections on the Hewitt report. Welcoming the emerging focus on what I describe as the HOW of an organisation, "it is the HOW of the organisation or system of care which enables the effective execution of the WHAT". I also referred to the learning from my last assignment. In this organisation, at inception, the focus had been on legislation and governance, with limited attention given to how the organisation should work (the structure, behaviours, and enacting processes) and how this continues to impact its ability to deliver quality, performance & productivity goals consistently.
"Many of our biggest challenges are the result of complex, interlocking patterns of dysfunction, which are continuously recreated and reinforced through the rational choices of patients, partners, staff and policy makers". Charles Leadbeater & Jennie Winhall, The Patterns of Possibility: How to Recast Relationships to Create Healthier Systems, 2022.
My time with these fantastic people ended recently, and whilst they still have significant challenges, they now have an evidence-based organisation and system development route map. A coherent plan of the HOW.
The Focus on the WHAT
In my experience of the NHS over the last 18 years, the focus is on the clinical strategy, design of specific pathways (micro level) or the health economy (macro), and the WHAT and rightly so. However, an understanding of the HOW and investment in systemic interventions at the organisation level, remains limited. The talk concerns population health determinants, but what about organisational health and performance determinants? The meso-level building blocks, components which influence the ability to execute the WHAT.
It appears the performance of an organisation only becomes of interest when an outcome either indicates a failure to return a financial surplus or the quality of the WHAT deteriorates. Even then, the focus is often on the WHAT. How often does the HOW play a part in the diagnostic and subsequent intervention(s)? Whether internally led or externally by the regulator. Where does the HOW sit on the regulator's assessment and intervention agenda? An agenda that transcends multiple but similar organisations, all with the same determinants.
The Challenge
As I have already referenced, I recently had the opportunity to support the UK's second-largest healthcare provider, with a budget of £1.87 billion and a workforce of over 18,000. As one of eight Welsh Integrated Care Boards, it delivers healthcare services to over 700,000 people. The Health Board coordinates the work of public health, primary, community & acute providers.
A summary of the challenge put forward by the Executive Director of Workforce & Organisation Development and the newly appointed CEO was: "What do we need to do as an organisation and system of care to succeed in the achievement of our purpose and goals - how do we improve the performance and health of the organisation?" The term culture was used frequently as a reason for the poor performance.
My response: "An organisational development route map and delivery portfolio?to facilitate an improvement in the performance and health of the organisation". Provide an opportunity for people to reflect on what they see, feel & experience and collectively answer the questions:
- What goals are we striving to achieve?
- How do we know how we are doing as individuals, teams and organisations?
- How do we help each individual and team to improve each and every day?
- How are decisions made?
- How do we learn from our previous decisions?
- What unwritten rules, implicit standards and expectations exist that influence how we behave?
- Are the structures in place ones that we understand in terms of achieving our goals, endorse and value?
- How do we build on what we have achieved because of COVID19?
- How do we solve our BIG problems or realise our BIG opportunities? (Top-down or/and bottom-up)
- What do we need to do as an organisation and system of care to succeed in achieving our purpose and goals?
?An Integrated Health Board
The formation of the integrated care board happened in stages; separate sovereign entities brought together into "one organisation" – structural, governance and policy changes at the time were the primary task, with insufficient focus on the people (behaviours) and enacting processes.
There have been several significant changes to the structure since, resulting in roles and structures becoming complicated and confusing, making it challenging to navigate the organisation. These changes, led by numerous Chief Executives and a high number of senior interim posts over a relatively short time, had created operational instability and ambiguity of strategic delivery - people had lost sight of the organisation's purpose & goals and how they contribute. This compound effect meant that the organisation has been unable for many years to deliver its quality, performance & productivity goals consistently. As a result, special measures became the default framework in which it operated. Consequently, leaders had become disempowered, accountability and responsibility ambiguous, and a sense of learned helplessness had emerged.?
Numerous external reviews, each providing repeated recommendations, including, but not exclusive to;
- Strategic clarity – integrated strategic thinking and planning.
- Strategic deployment – a clear line of sight from the Board to the front line and back.
- Operating framework – designed to enable the delivery of the purpose - integration of the structures and processes underpinning financial, corporate, and clinical governance with clear accountability and decision rights.
- Leadership capability building across all professional groups.
- Change & improvement – organisation-wide approach.
Whilst the organisation had endeavoured to address these recommendations and had undoubtedly made progress, this had not translated into sustainable change. There was a recognition that delivering these recommendations, along with several other factors, could provide significant improvements, including:
- Improved quality and outcomes and less avoidable harm through a more skilled and innovative workforce, who share their knowledge not just to foster innovation but, paradoxically, also as the primary way to drive standardisation.
- Improved performance - through workforce alignment to the common purpose and an integrated operating framework.
- Improved productivity – through a workforce capable of self-generating and self-organising planned incremental improvements via a systematic approach.
?
?"Every system is perfectly designed to deliver the results it gets" Paul Batalden
The HOW
I developed a proposal entitled 'Stronger Together', an architecture, but more importantly, an evolving movement that would co-design the Strategic Organisation & System Development route map. It was accepted in 2020 by the Executive Directors and Board members. The approach to this ambitious work was framed by extensive evidence-based research, emergent knowledge and experience, which identified the interdependent determinants, the components, the meso building blocks which create the conditions for and are associated with organisation (and system) performance & health. The HOW of the organisation which enables the effective execution of the WHAT (clinical care).
Whilst the illustration below projects a simplistic message, the reader should be under no illusion of the complexity associated with the interdependent components.?
?The Routemap
The development of the route map had three distinct phases:
1.???Discovery – the evidence to describe the current state.
A combination of qualitative and quantitative analysis achieved by virtual one-to-one conversations and group sessions, online surveys, and document and data reviews informed the current state & why. I led the multi-disciplinary team of highly skilled internal & external Organisation Development Practitioners, Communications Leads, and a Portfolio Support team to engage with 1800 staff members (10% of the workforce). A systemic approach encompassing multiple lines of enquiry categorised into eight domains. Over a hundred documents were reviewed, including previous commissioned reviews and the organisation's numerous plans for change.?
The discovery outputs were shared with the Board and widely across the organisation. A summary of the key meta themes is detailed below:
- Purpose & goals – a need to reset & connect with staff.
- Behaviours – co-development of shared standards.
- Engagement & communication – face-to-face needs to become the default approach.
- Role & responsibility - establish clarity at executive and senior leadership levels.
- Multi-divisional team working - create the conditions to encourage & enable.
- Decision making - develop a clear framework to empower.
- Leadership development – the need for an integrated development framework.
- Structure – needs to be aligned with the organisation's purpose.
- Significant change – the need to develop capability & capacity across the organisation and realign existing initiatives.
- Small change - a systematic continuous approach to self-generate and self-organise planned incremental improvements.
- Personal contribution – needs to be clear & informally, and formally recognised.
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?2.???Design phase – an evidence-based development plan.
The long-term target condition and associated strategic interventions required to close the gap were co-designed. Delivered via a portfolio of five interdependent change programmes with associated output and latent outcome measures. Informing the core of the organisation's 2022-2025+ People Strategy & Plan.
The portfolio of change programmes is described below:
a.???Our way of working
This programme aims to establish what individuals and teams value & how each person treats each other, including how colleagues are listened to and supported. A behavioural compact, internal non-digital communication system, and integrated leadership development are just some of the example projects.
b.???How we organise ourselves
This programme aimed to align the structure to the purpose, establish clarity of role & responsibility at the executive and senior leadership levels and develop a clear framework for empowerment. Six design & delivery sub-projects spanned the domains of 1) clinical service design, 2) enabling services design, 3) governance, goals, finance, measure, and information deployment, 4) integrated health communities, 5) roles & the people, 6) leadership development & support for emerging teams. An independent organisation designer led the strategic co-design process.
c.???Strategic deployment (Golden Thread)
This programme aims to enable all staff to understand how they are doing in their role and how they connect to the health board's purpose and goals, as well as the development of an infrastructure and approach which facilitates learning from decisions taken. The scope of the projects covers goal deployment, information & performance (at macro, meso and micro) alignment and an organisation-wide appraisal system.
d.???The best of our abilities
The programmes' purpose: make it easier to get the skills and capacity the organisation needs from both within and outside. The portfolio of projects spans workforce planning and commissioning, multi-professional education and learning integration, joining & leaving well, talent & career framework, and a corporate services development approach to business partnering.?
e.???How we improve & transform
Improving the way large-scale change is identified (quality, performance & productivity), delivered & managed, as well as continuous improvement & coaching skills. Alongside the ongoing work to consolidate and realign the organisation's existing portfolio change initiatives.?
?3.???Delivery phase.
The programme 'How We Organise Ourselves" was launched first. The implementation of phase one of the new operating structure, which spanned levels two (Executive Directors) to five.?A complex programme which carried significant risks to performance. The four other programmes subsequently followed. As an emergent process, the composition of the portfolio of programmes has and will continue to adapt through the delivery lifecycle.???
An illustration of the approach used with indicative timescales.
Achievements to date
A snapshot of the work achieved to date includes:
- An evidence-based mandate for changing the HOW.
- A people strategy & plan 2022 -2025+ – this includes several interventions which mirror the recommendations from the Messenger review of NHS leadership, 2023 – including leadership capability building, appraisal and talent and career framework development.
- A movement of 1800 agents of change.
- An operating structure which supports the purpose of the organisation.
- Emerging clarity of role and responsibility at an executive and senior leadership level.
- Start of the consolidation of the plethora of organisational change initiatives.
- A leadership development network.
- A new joining well and leaving well process.
- An emerging awareness and knowledge of the symbiotic relationship between the WHAT and the HOW
The organisation still faces many challenges; implementation of the interventions by the programmes will take years, and the expected outcomes even longer. I was clear on those timescales and the influence that capacity, capability, and politics can have on output and outcomes delivery.?
My reflections
The failure to focus on the HOW of the new emerging ICB (2009) contributed to many of the performance challenges the organisation faces today. Since inception, attempts had been made; unfortunately, the interventions had been fragmented, designs flawed and not delivered at scale, compounded by the lack of an organisation-wide improvement approach.
"Too often, we set the right goals inside the wrong system. If you are fighting your system each day to make progress, then it's going to be really hard to make consistent progress." Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones, James Clear, 2018.
The dissociation in the minds of some board members and senior leaders of the interdependent factors of behaviour, structure and process has also contributed. The term culture was used frequently as a reason for poor performance, a term misunderstood. Knowledge transfer was a critical part of this assignment, and helping individuals to understand that culture is a manifestation of people's behaviour influenced by structure and process helped those individuals to understand the complexity of the challenge they face. Whilst progress to end this dissociation in the minds of the regulator(s) has begun, the thinking is still very much emergent.
It would be remiss of me at this stage, not to mention the effect of the workforce deficit on NHS organisations to deliver the triple aim – improving quality, performance & productivity. Nevertheless, closing the workforce deficit alone wouldn't answer the mandate that was set.
The individual components are themselves complex disciplines, but on their own, they don't improve the whole. In an organisation that continually improves in terms of performance and health, it is not so much the individual parts that matter but how they come together, connect, and interact to create the whole -irrespective of the organisation's purpose, size, and form. A whole which needs to be designed, reviewed, monitored, and continually improved. All the components have a critical role to play, but the one component which connects the rest and drives the interaction is leadership. The behaviour, the signals and signs that inspire, energise, and mobilise, this was evident at the health board.?
?"It is all too easy to remove a chief executive but fail to address the underlying systemic challenges that make some roles extremely difficult". The Messenger Review of NHS leadership: what you need to know, NHS Providers, 2023.
This was a complex assignment with many variables. It was clear from the discovery, of the impact of the HOW and it's influence on the ability to deliver the WHAT.
Michael Shaw
Independent Thinker - interested & experienced in supporting systems leaders to transform large-scale systems of care.
Want to know more: let's say hello or grab a coffee (real or virtual) for an initial discussion or email me at michaelshawassociates@outlook.com to start a conversation. +44 (0)7739 687907
Director NHS Wales Employers
1 年A very interesting read Michael.. it was and remains the right thing to do if the organisation is going to embrace the power of its people. An interesting reflection perhaps on Organisational readiness or perhaps more appropriately in this case, the impact that leaders can have upon doing the right thing.
Michael, it was a great pleasure to be part of the assignment and work with you on this piece of work. We believed completely in the Stronger Together Architecture and the OD route map.