How can national policy makers support local change? How can those working in Whitehall’s Ivory Towers help, not hinder, those working on the NHS front line? Having spent the last fifteen years working in national policy roles, in both the Department of Health and NHS England, it’s a topic I’ve spent a lot of time thinking about.
One of the great things about being a civil servant is the variety of fascinating areas you get to work on. For me, this has included working on urgent and emergency care policy, implementing a primary care commissioning strategy, taking a bill through parliament and working directly for ministers in their private office. Despite the variety of areas, there are common facts of life. Deadlines will be short. Ministers will ask questions which may not entirely be relevant. If Number 10 are calling you up, it’s almost always a bad sign. My work on our report, Constructive comfort: Accelerating change in the NHS, has made me recognise some further realities about the nature of national policy making.
The first is how policy always needs, but rarely has, a ‘theory of change’ to set out how action nationally will link to local action. We often spend time carefully crafting national policy ideas without fully understanding how this will translate in practice and affect those working to deliver care.
The second is that our tools of the policy trade, invariably described as ‘policy levers’, are often limited in their ability to achieve the change we want. Our traditional focus is to nudge or prod providers through familiar tools such as targets, payment incentives and regulation. However, evidence tells us that while these tools can improve performance in targeted areas, they do not have the track record in delivering the sort of transformational change now required across the NHS.
So why do policymakers do this? I know from experience that understanding how successful change happens in the NHS and the barriers frontline staff deal with every day are not always well understood in policy circles. While we may think we think we have a good understanding of how policy decisions impact on the front line through stakeholder interactions or personal contacts, it’s easy to become detached from the real challenges involved in making change or improvement happen.
I have experienced this myself, having led the Department of Health (DH) team responsible for NHS delivery (requesting improvement plans and updates) and then been on the receiving end of those requests on secondment as a commissioner a few months later. Something that I'd thought was a fairly simple request when working at the DH was actually very time consuming and ended up dominating my week. This meant I had to put a local change project on the back burner to deal with this as a priority.
This is exactly the sort of issue that was echoed by numerous frontline professionals we spoke to in the development of our report. It's certainly due, in part, to a lack of policy makers with actual experience of delivering change in the NHS, both at the DH and its arm’s length bodies. This has been highlighted as a concern by others. For example, the Public Accounts Committee raised concerns that Monitor’s ability to diagnose problems and develop solutions was compromised because only 21 of their 337 staff had ever worked in the NHS. There have been recent efforts to try and address this deficit with initiatives such as the DH’s Connecting Programme, which sees civil servants swapping the corridors of Whitehall for the NHS front line for one month per year.
The programme is certainly a step in the right direction in helping policy makers understand the realities of the delivering care, but I don’t think it goes far enough. As we set out in our report, national policy makers are still taking too narrow a view of how to effect change in a complex adaptive system like the NHS. This view is supported by the Institute for Government in their work on making policy better. They make the point that central government often cannot exert direct control over how such a complex system works.
So what should national policy makers do differently? For me, it is recognising that the key to delivering the sort of transformational changes needed lies not in national policy levers, but in the ability of frontline staff to build strong local relationships, agree common goals and then have the freedom to take action. We suggest a more balanced approach to national policy in our report which is more supportive and staff-focused, helping individuals who work in the NHS to make local change happen. More of the same is no longer an option – as Henry Ford said: 'If you do what you've always done, you'll get what you've always gotten.'
Clare is a Senior Policy Adviser at the Health Foundation, www.twitter.com/clareahealth
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