Failure in the NHS has received much attention in recent years, particularly in England. The Francis report into the failings in care at Mid Staffordshire NHS Foundation Trust and the Berwick review into patient safety both highlighted the need for NHS leadership to recognise and learn from failure. This is especially relevant for delivering more efficient, effective and integrated care while balancing finances. In July 2015, the Secretary of State for Health called for the NHS to foster ‘an inquisitive, curious and hungry learning culture’. In times of austerity, with increasing numbers of trusts struggling with quality and financial metrics, how to avoid and recover from failure is prominent in NHS policymakers’ minds.
So how is failure being evaluated in the NHS? The Care Quality Commission (CQC) placed 26 NHS trusts in ‘special measures’ from 2013 to 2015. While some have remained in special measures, the good news is that others have been able to demonstrate a rapid turnaround. For example, University Hospitals Bristol Foundation Trust went from ‘requiring improvement’ in 2015 to ‘outstanding’ by its next inspection in 2017. An organisation’s ability to bounce back relies on health and social care leaders really understanding the failure, learning from it and then effectively focusing time and resources on recovery. And to avoid history repeating itself, providers also need to create resilient organisations capable of adapting to significant and, at times, unpredictable changes.
It was against this backdrop, in 2015, that the Health Foundation’s Policy Challenge Fund asked two fundamental questions. What are the lessons that policymakers can learn about failure from other sectors? And what are the responses that can build resilient NHS organisations for the future?
In response, a team from the University of Leicester and Cardiff University examined failure, recovery and resilience in the criminal justice system (policing, youth justice, prisons) and education. Our research examined the journey to recovery for six previously failing or poorly performing organisations, to identify the key strategic themes and actions that are relevant for health care policy and practice. It includes over 50 interviews with members of staff from the six organisations:
- HM Prison Brinsford
- Northamptonshire Police
- Gwent Police
- Newport Youth Offending Service
- Sirius Academy North
- Crawshaw Academy.
An important concept to aid organisational recovery and improvement is organisational resilience. The concept of organisational resilience has gained increasing interest among both leadership and academic communities. It can address some fundamental questions, such as: why do some public sector organisations overcome and recover from disruptive events and failures and others languish in failure regimes or special measures? And what enables these organisations to adapt and recover from these events?
Underpinned by resilience theory, our research took place over three stages: an evidence synthesis, in-depth case studies and a policy workshop. Resilience theory is taken from ecology literature and has more recently been applied to psychology, human behaviour and strategic organisational management. Ecological resilience theory – originally developed by C S Holling in 1973 – was adapted and used to identify effective strategies for public sector failure prevention and recovery. Within Holling’s approach there are three broad systems surrounding resilience:
- engineering resilience – the ability in terms of speed or status of any system to return to an equilibrium (original or revised) following any disturbance
- ecological resilience – the ability of a system to absorb or resist unrest, maintaining its stable state. This applies in terms of function, purpose, structure or identity, and permits necessary changes to key mechanisms or functions of the system
- adaptive capacity – the ability of a system to manage and accommodate change, and to adapt to disturbances. A key aspect of adaptive capacity is that systems make themselves resilient by continually varying their key functions and processes so they are prepared to adapt when a disturbance occurs.
Our research revealed common strategies across the different sectors and case studies, all of which sought to foster organisational resilience across these three dimensions. For example, engineering resilience was achieved through substantial changes, such as restructuring or replacing the leadership team or team members.
Ecological resilience was gained through implementing transparent processes, regular reviews, governance and quality assurance processes, as well as developing new or improved relationships with external bodies and agencies to provide peer and external reviews.
Adaptive capacity was shown by organisations taking an expanded perspective, working with other agencies, inspectors and regulators to tackle common problems. By increasing communications with employees, stakeholders, service users and the community they served, case study organisations created open and transparent learning cultures that were able to adapt quickly to feedback and changing priorities.
We have used our findings to develop a tool for leaders of NHS organisations, to help them deploy limited resources in the most effective way to build organisational resilience. Our research and that of others suggests that organisational resilience theory can provide a useful framework to aid rapid recovery from failure across a range of public sector organisations. There is indeed much that health care policymakers and NHS leaders can learn from failure in the criminal justice and education sectors.
Dr Ceri Jones is Senior Research Fellow at the School of Social Sciences, Cardiff University. @DrCRJones