How can the NHS become better at change?

• Our new report looks at how national bodies can support and accelerate local change in the NHS.
• The report identifies seven success factors for change in local organisations and barriers in four main areas.
• Recommendations for national bodies on supporting local change include more support for and focusing action onpeople working on the front line.

Why is change in the NHS so hard? And how can national bodies (such as Monitor, NHS England, and the royal colleges) help make it easier? Our report Constructive comfort: accelerating change in the NHS takes a look at these issues. While it focuses on the English NHS, there are also broader lessons for health services across the UK (view an infographic of the headlines and key messages).

The NHS five year forward view (the Forward View) sets out a clear vision for a future NHS in England with a greater focus on prevention, patients more in control of their care, and the breaking down of barriers in how care is provided. The aim is for this to result in leaner, more efficient, higher quality health care. So to some extent, we know what needs to be done, but do we know how the NHS can be supported to make this change happen?

There is broad agreement that change needs to be locally led, with the role of national bodies being to support those delivering care. However, central policy is not yet designed effectively to support the delivery of the Forward View vision. The experience of many working at the front line of care is that the actions of national bodies can be contradictory and unhelpful – hindering change as much as helping.

For example, are national bodies:

• supporting recognition of the need for change when chief executives of trusts in special measures risk removal, while their consultants are more likely to receive clinical excellence awards than be dismissed?
• creating an environment in which there is sufficient motivation to change when foundation trusts are pressured to put their short-term financial success ahead of the creation of a sustainable future for their local health economy?
• creating the headspace to make change happen when dips in performance are accompanied by multiple demands for assurance, but limited offers of support?
• building and supporting capability for change when every reduction in managers is celebrated by politicians, making change ever harder?

What drives success? What stops it?

Our report draws on a number of sources: our experience of supporting improvement, interviews with leaders in national bodies and professionals working on the front line, and a review of the published research and evidence.

From this work, a clear picture emerges of what characterises successful change, shown through the following seven success factors:

1. Committed and respected leadership that engages staff
2. A culture hospitable and supportive of change
3. Management practices that ensure execution and implementation
4. Capabilities and skills to identify and solve problems
5. Data and analytics that measure and communicate impact
6. Resources and support for change
7. An enabling environment which supports and drives change

However, despite wide recognition of these factors, we found they are not commonly present in the NHS in England. This means efforts to improve services and drive change across health economies are more difficult than they need to be.

Our work identifies barriers to change for staff and organisations in four main areas: recognising the need to change, having the motivation to change, having the ‘headspace’ to make change happen and having the right capabilities and skills.

What do national bodies need to do differently?

Broadly, national bodies can support change in the NHS in three different ways:

• Type 1: 'Prod organisations' approach – externally prodding and nudging organisations to behave differently, for example through the use of incentives, targets or regulation.
• Type 2: 'Proactive support' approach – supporting organisations to change, for example providing access to capability building and improvement expertise.
• Type 3: 'People-focused' approach – focusing on policies which directly impact on individual staff (such as education and training), as well as engaging and inspiring people working in the NHS.

We believe that the balance between the different approaches can be improved. The ‘prod organisations approach’ is used too much, and the ‘proactive support approach’ too little. In addition, policies from the different types of approaches do not align and can be contradictory.

Our recommendations

We recommend that national bodies take a different approach:

Immediately develop a shared view of how change happens in the NHS and what national bodies should do to catalyse it
This should be created with leaders of frontline services in an ongoing way and inform all national activity.

Develop the current blend of organisational policies to best support change
In particular, align and redefine national measures for local success, moving from a narrow view based on short-term performance to include the conditions for successful change and resilience.

Invest far more in support for change, starting with a coherent improvement strategy for the NHS in England
This strategy should include concrete suggestions for how supportive approaches can make improvements in the short term (ie within a year), as well as how regional support will develop over the medium to long term.

Focus action on people working at the front line
Policy should start with how it will support individuals to improve care. A great deal more work is needed to establish how current staff-focused policies can be developed and aligned to support change, as well as how these blend with the prod and proactive support approaches being pursued.

Taken together, these recommendations can give the Forward View the best chance of success.