My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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Managing change in the NHS

Filed Under (Culture of the NHS, Reform of the NHS) by Paul on 10-11-2010

Managing the current change in the NHS – which will itself change part way through and will need to be managed – will lead to a constantly changing NHS.

On Monday I spoke to a regional conference of CEOs and Medical Directors of NHS organisations together with their local authority counterparts. The Conference was discussing how to manage the reform programme over the next few months given the complex nature of the changes. Some organisations that were not yet formed (GP commissioning consortia), would, over that period, come to prominence. While some of the organisations in the room would decline very speedily in influence.

The conference had been called by the SHA, but they also realised that, in a few month’s time, their authority to call such a conference may well have waned completely. If it were to happen next spring someone else will have to call it. It was clear that the levels and experience of change that senior managers were going through would be  – as the psychoanalysts say – multi-layered.

  1. Managers have to deal with the changes that are consequent on the Government’s reform programme. In itself this is a complex task calling for adaptive leadership – which in some cases involves people developing their own abolition.
  2. A second concern is that the nature of these changes will be consequent on a piece of legislation that has not yet been published, and will be changed as it goes through Parliament over the next 11 months. So these changes themselves, as they go through Parliament, will themselves be changed. For example, changing commissioning in line with the current view of how GP Commissioning Consortia will work is a vital part of managing the reform. But, almost certainly, as this part of the legislation goes through Parliament those new organisations will themselves be changed.
  3. After that there will be further change once the reforms have been implemented and the new system has bedded in. The whole aim of these reforms is to create an organic process of change that would no longer need state sponsored reorganisations to bring about further change. Change would then continue to happen organically, as they do in other markets, with the growth and decline of organisations.

These layers of change calls forth from public service managers a very different set of skills than has traditionally been the case. Consequently the buzzword and emotion at the conference was the need for adaptive leadership. This sounds straightforward. After all who can be against a strategy that develops a leadership that adapts? But, as this blog has commented on many occasions, culture eats strategy for breakfast. Whilst there may be a strategy which demands adaptive leadership, non-adaptive culture will swallow it. Actually becoming adaptive within a culture that has not been adaptive in the past is very hard.

I gave a presentation on the nature of management that would be necessary during the reform programme. (Attached as an appendix). But what was interesting in the questions and in the discussion in the margins of the conference was the scale of the different reaction of senior managers to this complex management task.

Some people in the audience had really shining eyes at the prospect of what they were going to have to do. The very fact that they could not really know what was going to happen in the next 2 years and therefore what they were going to be responsible for seemed to really thrill them. They knew that the next few years will stretch them beyond their experience of the last few.

Then there were others who looked at me, and having listened to what I was saying about managing all this change, thought that I had come from a naïve planet on the other side of the solar system. The NHS has been within one style of management for some time. It has developed a powerful management style and system from the top. And that won’t change. And of course this weird guy is talking about this level of change but really it’s not going to happen… is it?

And then there were the others. Understandably caught between anxiety and excitement and waiting to see whether this new environment is really going to happen.

Once the Bill is published the first level of adaptive change needed will be clear.


Managing NHS organisations from here to there. How can NHS reforms add value to the core business of our organisations?

The NHS now really moving from an organisation to a system

The Coalition Governments reform programme and the White Paper

Changes in the National

Changes in commissioning

Changes in provision

Changes in the transactions between commissioning and provision

The timetable

How to use the reform levers to lead institutions that will improve health care

The NHS now really moving from an organisation to a system

The NHS is (still) used to thinking of itself as a single organisation (It after all has a Chief Exec). This means Chief Execs are merely a part of the organisation (Management method No 1 is this one)

For some years it has been developing as an interlocking system with CEOs have responsibility for their organisations but with the DH in charge. (Management method number 2)

In the future it will become a system with no single person in charge and a set of rules created and administered by a regulator. (Management method number 3)

The Coalition Governments reform programme and the White Paper

The reforms within an overall architecture

  1. What is the responsibility of the National in the English NHS?
  2. Who is commissioning health care and how are they doing it?
  3. Who is providing health care and how are they organised?
  4. What are the transactional relationships between commissioners and suppliers and how are they organised?

Changes in the National

The “Head Office” of the NHS in DH goes

National Commissioning Board set up receives annual resource and mandate from SoS but is not Whitehall. DH is the client side

NCB is a new form of organisation doing new things

NCB commissions GP services; national and regional services and some others (maternity)

NCB distributes resource, provides contracts/performance management to GP commissioners consortia and has a duty to ensure universal coverage of GP consortia

DH runs National Public Health Service

DH provides resources (4-5% of NHS) for local commissioning through local authorities

NICE now goes as Vfm decider for drugs

CQC registration remain

(Problems of the accountability of the NHS to Parliament)

Changes in commissioning

The commissioning of GP services has been nationalised

Statutory based GP led commissioning consortia to be led by an accountable GP. To use GP medical skills of referral and the small business skills of economics.  Held to account for outcomes by NHS Commissioning Board

Every GP practice a member of a consortia Changes in the GP contract

Consortia need to be small enough for all practices to recognise and give allegiance

Skills for commissioning could be organised at a higher level than consortia

PCTs abolished April 2013

Public Health commissioned through Local Authority- creation of Health and well being board.

Changes in provision

‘Largest and most vibrant social enterprise sector in the world’

Within 3 years all NHS trusts to become FTs and the non FT trust model is withdrawn to provide incentive

Where a trust is unviable SoS may apply to put into administration – development of a failure regime and recognition of what happens when institutions fail. Take overs and acquisitions.

Easier new entry for private and third sector providers Level playing fields with public and private patients choose between providers

Information revolution to empower the public

Much fuller influence of the market would bring some dramatic interventions between primary and secondary care and will bring rapid change.

Changes in the transactions between commissioning and provision

Monitor becomes an economic regulator as in other quasi markets (see the utilities for the best example). NOT politically accountable

It has the duty to ensure access and will promote competition and apply competition law (this will have to be done slowly given monopoly position)

Power to intervene in event of failure of service providers.

CQC will provide licence to trade

The timetable ??

Bill introduced October/November After Second reading power to set up shadow orgs.

Shadow NCB established 2011

Shadow GP consortia established 2011/12

Local Authority Health and well being boards April 2012

NCB fully established April 2012

Monitor established as an economic regulator April 2012

GPs consortia formally established during 2012

SHAs abolished 2012/2013

PCTs abolished from April 2013

How to use the reform levers to lead institutions that will improve health care

Something like this is going to happen.

There will be much more movement in the new system and it will always continue as organisations grow, change and fail organically

GPs come from the land of small; NHS managers come from the land of big. They are very different and the land of the small is going to have the commissioning money.

It may be that the centre of NHS management skills shifts irrevocably from running provision to commissioning it.

Under any circumstances NHS managers will need greater agility because of resources even more than these reforms


One Response to “Managing change in the NHS”

  1. Hi Paul
    I was at the SHCA conference on 16th November where you presented. There was some debate about how NHS specialised commissioners would need to engage closely with the private sector in future arrangements to effectively commission specialised services. NHS commissioners however are very wary about even speaking to the pharma industry, let alone working in partnership. What more do you think can be done to facilitate engagement between specialised commissioners and pharma?

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