It feels like Groundhog Day. We spend hours in meetings with other NHS and Social Care leaders working through system transformation plans that we secretly know are doomed to fail. We each play our part, saying the right things, voicing our optimism, yet we all know we are setting ourselves up to fail.
During the last decade, in South West London alone, strategic plans were abundant: “Better care: closer to home”; “Healthcare for SW London”; “Better services: better value” and “SW London acute care collaboration”. Will STPs be different, or are we simply going around the same loop again?
Successful change is all about people. Kotter’s influential 8 change steps are entirely about engaging and influencing people, and managing resistance. There is no mention of Gantt charts, spread-sheets or project plans.
Yet the NHS is failing to grasp the nettle and have frank and honest leadership conversations. We should not be surprised then to see defensive behaviour and barriers created. This is not because the people are bad. It is because our change processes ignore the human dynamics of change amongst our most senior leaders and structures, incentives and penalties are prohibitive to change.
CEOs, Chairmen, Boards and Governors are all (ultimately) accountable to their local population. STPs threaten some local services and we have seen the fervour of local people fighting tooth and nail to retain their local A&E or maternity service. This aspect alone presents a tough leadership challenge.
Furthermore, NHS planning processes use a logical approach to strategic planning. While the plan may logically stack-up, it frequently fails to take account of the human dynamic of change – the people factor! The belief that logic will triumph over opposing interests is fundamentally flawed and grossly naïve.
The planning process becomes a chess-like tournament where players attempt to predict and block others’ moves to ensure they “win”. We work together to agree logical change criteria, arguing for criteria that benefit our organisation. Those who lose, by being ‘out-played’ or where logic is weighed too heavily against them, resort to underhand tactics such as leaking key documents, calling in high profile local politicians, stirring up local protests and lining up clinicians to declare the plans deleterious to patients’ care.
There is, however, a way to break this doom-loop cycle, a way to stop the madness of trying the same thing over and over again and simply hoping, this time, things will be different. We can change the approach to one much more focussed on supporting the people responsible for delivering the change.
This requires two things.
- Expert neutral facilitation of leadership conversations in a safe, confidential space. This is critical to gaining a deep understanding of the issues as well as creating genuine trust and mutual support. It enables open, honest conversations and collaboration between leaders and encourages co-creation of win-win solutions.
- Regulator and commissioner support and ‘headroom’. Regulators and commissioners must understand and acknowledge the implications, risks and consequences of the proposed STP changes for each organisation. They must give support and flexibility with performance targets, and tolerance of financial thresholds which are harder to maintain during transition.
Notwithstanding financial risk, the loss of a service, for example, creates a domino effect of clinical, sustainability and other risks. Key staff quickly seek other, more secure jobs and replacing them becomes virtually impossible leading to escalating agency costs. A transient workforce creates quality risks and meanwhile stakeholders, local politicians and local media bring huge pressure to bear. Senior leaders struggle to retain the confidence of patients, staff, the public and their up-the-line masters. Their only option is to revert back to unilateral behaviour and fight for their organisation.
But when a collaborative and supportive approach is taken, real change results.
In South West London, St Georges, Croydon and Kingston successfully merged their pathology services. The senior leaders met regularly, formed their ‘guiding coalition’ and worked through the issues together. When the numbers were crunched, two of the Trusts stood to make a significant saving and one faced a loss. But savings could only be realised if all three Trusts were involved. So they agreed to share the benefits, and give some of the savings to the third Trust, thus creating a win-win. This was only possible because the three CEO’s had built strong trust, shared concerns and risks, and took ‘cabinet responsibility’ for collectively solving problems and agreeing the way forward. And they were supported by all SW London CCG’s who gave funds to support the project work and helped manage risks such as maintaining the confidence of GP’s during the transition.
STPs must succeed. To do so requires STP’s to create processes that enable and build trust and collaboration amongst organisational leaders and regulators to actively support NHS leaders with the local consequences of working collaboratively for the greater good.
 Kotter J and Rathgeber H. “Our Iceberg is Melting”. Macmilan Publishers Ltd, London (2006).[A version of this article first appeared in the Health Service Journal (HSJ) in September 2016, by Kate Grimes and Karen Castille – My thanks to Kate Grimes for her collaborative contribution]