Next steps in health system transformation
This Care Initiative event was held at Green Templeton College on 13 December 2017. This report was written by Senior Research Fellow Professor Trish Greenhalgh.
Few people are better qualified to talk about next steps in health system transformation than David Hunter, Professor of Health Policy and Management at Newcastle University’s Institute of Health and Society. Despite wind, rain and the dregs of snow and ice underfoot, his evening seminar was well attended and informal talk continued until Ruth finally succeeded in coaxing us all out of the lecture theatre more than half an hour after the advertised end time.
David’s interest in health system transformation goes back several decades. It embraces what he views as three ‘eras’ of health and social care: the period up to the 1960s, which focused on diagnosing and managing acute disease; the second half of the 20th century when attention turned to prevention and management of chronic non-communicable diseases (what we now call ‘long term conditions’); and the 21st century – characterised by multiple interacting and changing agendas including disease and its risk affecting the entire life course, the question of health equity, the need to [re]balance acute care and prevention, and the need to engage individuals and communities as co-designers of their health.
Not only have the demands on the system increased, argued David, but the policy environment has become far more challenging. He used the metaphor of “perpetual white water” to depict an environment characterised by information overload, shifting organisational and professional boundaries, interconnectedness of systems, new ‘disruptive’ technologies and a new generation of health and care staff with different expectations and values.
The challenges posed by the third era are not unique, or confined to, the UK’s NHS. They are confronting health systems globally and form a major work stream in WHO Europe.
In short, health and social care has shifted from simple to complicated to complex – but neither healthcare organisations nor those who lead them are well-equipped to cope with this complexity. The stage is set, David warned us, for implementation failures.
Drawing on work originally published in 1992 by Andrew Pettigrew and colleagues on ‘receptive context for change’, he identified five key elements of successful health system change: the external environment, especially the prevailing political (and, as comments from the floor pointed out, regulatory and legal) context; the quality and coherence of policy; good leaders; supportive organisational culture; and positive managerial-clinical relationships. Alignment between the vision articulated by an organisation’s leaders, the feasibility of the change and what might be called sense-making and action by the rank and file is key.
Most problems for which we seek health system change are ‘wicked’ – that is, characterised by ambiguity, unpredictability, political undercurrents, multiple stakeholders pulling in different directions, inherent contradictions and changing requirements. They do not have clear solutions; solving them is often a matter of “muddling through”. To that end, suggested David, we should rethink leadership to move from a ‘targets’ approach to a ‘systems’ approach.
The ‘complex adaptive leader’ is politically savvy; pays careful attention to relationships and context; understands and values the culture of the organisation as well as its structure; emphasises collective intelligence over individual genius and distributed over ‘heroic’ leadership; creates conditions that favour emergence and self-organisation; knows that complex (and desirable) outcomes can emerge from good enough vision and minimum specifications; sees paradox and tension as opportunities rather than constraints; uses the ‘soft power’ of persuasion rather than command and control; and taps into the dynamic energy of natural networks.
David explained all this through the metaphor of jazz to capture the loose-tight balance needed to bring about successful change: on the one hand, there is a tight structure and a disciplined environment; on the other hand, there is an emphasis on improvisation through co-ordinated team interaction. Can health and care organisations achieve the ‘loose-tight’ dynamics of a good jazz group ?, he asked. The chief executives in the audience hummed to themselves…
This audience (academics, policymakers, managers, clinicians) seemed to love complex systems thinking – but they were less interested in the abstract ideas than in the question of why it was so hard to apply them to the realpolitik of system change in the UK public sector.
David led a lively discussion on the NHS Five Year Forward View which seemed, at least in principle, to draw on complex adaptive systems thinking. It prioritised a locality-based, intersectoral approach to prevention and wellness rather than (merely) reactive management of sickness and disease. It encouraged local solutions, exemplified by 50 ‘Vanguards/New Care Models’ around the country based on four ideals: clinical engagement, patient involvement, local ownership and national support.
One or two people in the audience had been involved in one of these Vanguards and, bearing the scars, pointed out that it wasn’t easy to square the circle between a consistent national policy and emergent local solutions, especially with an oppressive, bullying, government-imposed target culture and the shrinking budgets of a fiscal ice age. Perhaps, admitted David, the scale and pace of change expected of the Vanguards had been unrealistic, especially when local teams were expected to make savings from the outset. Political hunger for early wins meant that many Vanguards slipped into a top-down management style because the ministers were waiting for their results and hungry for good news stories.
It would have been better, David suggested, to “allow these new models to breathe and experiment and even fail” (thereby generating learning and creating partnership synergies for longer-term efforts) rather than focusing on “coming up with spurious successes to satisfy the ministers”. As the House of Lords put it recently, perhaps we need a cure for the endemic short-termism of current policy cycles.
Hear, hear, agreed the audience.