Integrated strategies to mobilise change

The ambition of the 10 Year Health Plan will need to integrate different approaches to change: mobilising to inspire, delivering specific priorities through change programmes and changing how we deliver to embed different ways of operating. We need to:

1. Build a shared theory and practice for how the big shifts will be achieved.
2. Use mobilisation methods to generate energy and commitment sufficient to navigate the many difficult choices ahead.
3. Create space for staff to design and implement improvements. Back up inspiration with effective delivery to re-build confidence and agency.

4. Design transformation programmes to build momentum and learning around the three shifts. Effective design and delivery requires:

   a. Co-produced interventions, that are clear about the actions needed at all levels, what will be the same in all sites and what may vary locally
   b. Building sufficient capability and leadership support for the nature of the change
   c. Learning systems to measure change over time, and help identify, evaluate and scale examples of best practice. 

5. Change how we deliver day to day. Develop Quality Management Systems as a mainstream way to deliver transformation while maintaining quality of care.
6. Invest in structures and spaces to learn between places: in ways that reflect the evidence about how change spreads. 

With ​‘Change NHS’ attracting thousands of contributions, it’s clear people will have a lot to say on what they’d like to see from the health sector in the future. Yet agreeing on what is needed is likely to be easier than how to achieve it. The scale of change in the 10 Year Health Plan will require the millions of people who deliver and access health care to act differently: a participatory co-produced approach cannot stop with the current consultation. 

Leaders will need to build a shared theory and practice for how the big shifts will be achieved that feels different to how we often work in the sector. We need to deploy four different approaches to change in a thoughtful and integrated way:

• mobilising to inspire people who will need to change their practice
• delivering through change programmes to demonstrate traction on key priorities
• changing how we deliver to embed different ways of operating
• This in turn needs deliberate enabling work, ensuring the right resources, leadership support and policy environment. 

The rhetoric of mobilising change from DHSC is encouraging: Paul Corrigan describes the 10 Year Health Plan as ​‘re-imagining the NHS’. This calls for thinking and acting beyond current structures and modes of delivery.  Wes Streeting introduced the Change NHS consultation with the reflection that, ​“the best ideas are not going to come from above.  They have to come from all of us.” This brings front of mind that change is delivered by people, and this needs a common purpose. It will need sustained energy and commitment to reach consensus on many difficult choices over the years ahead.

Extreme operational pressures and eroded staff morale and engagement makes this particularly challenging. The NHS has (over)relied on discretionary effort, stretched to breaking point and beyond in recent years. The focus on productivity – which will be critical to make transformation sustainable – risks making this worse if it’s experienced by staff as finance-driven rather than part of a wider reform agenda seeking to enhance equitable quality of care.[ref]Williamson A and Patel P (2024) From the frontline: Empowering staff to drive the NHS reform agenda, IPPR. http://www.ippr.org/articles/from-the-frontline[/​ref]

Insight from the Q community suggests many are finding it harder than ever to prioritise and engage others in transformation. Creating space to design and implement improvements and re-building a sense of confidence and agency among staff should be considered essential foundations for the plan to succeed. 

Mobilising change mechanisms provide inspiration and hope: speaking to the relational as well as the rational case for change and reminding us why we get up in the morning. But rallying calls aren’t enough. That inspiration needs to continue through our working day. Implementation also needs structured delivery: approaches to the day to day work of the plan that are productive and satisfying because people are effectively engaged. 

The 10 Year Health Plan demands we get better at strategically integrating innovation and incremental improvement activity.  NHS Confed, the Q community and Health Foundation have developed a framework that builds on NHS IMPACT and change strategies from across the UK and Ireland. It supports this strategic integration, identifying and embracing the distinct considerations that will be needed to deliver effectively across places and systems. 

The 10 Year Health Plan is an opportunity for change delivery that’s strategic rather than reactive.  Effectively designed transformation programmes will be needed to build momentum and learning around critical changes: whether that’s introducing integrated neighbourhood teams or smoothing flow to reduce waits and delayed transfers of care.   Q recently convened national improvement leaders to pool learning from decades of delivering transformation programmes on what would be needed going forward: 

• The commitments in the plan will need to be developed into interventions ready for delivery at scale.  This requires participatory co-design, informed by evidence. We need to more systematically define not just what needs to change but how to implement it effectively. For each specific change, we need to be clear what will be the same across contexts, what may vary locally and the policy, regulatory and commissioning factors that will need to evolve.
• When it comes to enabling delivery, the collaborative programmes that were critical to progress achieved in emergency care and elective waits following the NHS Plan in the early 2000s provide a sound foundation. Success depends on sufficient resourcing and investment in the participating sites and central support functions that design and facilitate these programmes.  The 10 Year Health Plan aims for ambitious, systemic change, demanding a more flexible approach and work to build the capability and leadership context on a much greater scale than was needed for earlier generations of collaborative programmes. 
• Collaborative programmes can enable participating teams to achieve great progress, but evaluation shows results can struggle to be sustained or replicated. Future programmes need greater investment in scaling to the later adopters and to embedding changes in practice. Learning systems, like those routinely built around programmes in Scotland, are needed to support measurement over time, and help identify, evaluate and circulate examples of best practice. 

The stakes are too high not to build on what’s already been learnt. Historically, there has been a lack of a systematic, evidence-informed approach to planning, implementing and evaluation of national programmes. The Health Foundation – working with THIS Institute – is currently learning from national programmes to develop design principles and guidance. 

As well as delivering change programmes, we need to change how organisations deliver their core business. As the Darzi report recognises, it’s not just that performance is ​‘broken’; how the sector is organised limits what can be achieved. 

Since the early 2000s, we’ve learnt that the spread and sustainability of specific changes depends on the context: the ​‘absorptive capacity’ of organisations and how well interventions are effectively embedded. Whole organisation approaches have become the goal, an evolution reflected in the NHS IMPACT approach. 

Widespread interest in Quality Management Systems points to the future: integrating systematic processes for planning, improving and controlling quality and other aspects of performance. Delivering transformation, while maintaining quality of care, will require dynamic and agile learning and management processes. For example, to realise the potential of Electronic Patient Records (EPRs) and other shifts to digital delivery, organisations will need to understand how needs, expectations and possibilities are changing. They need to prioritise and plan activity and resources to redesign roles and processes as technology is introduced, using improvement methods alongside HR, IT expertise, programme management and other skills. Mature control processes are needed to embed what’s achieved, learning and adjusting over time. 

How can DHSC enable this shift? It will require a review of financial flows and other incentives and a shift in culture. The clarity of the 10 Year Health Plan should lead to fewer central long-term priorities, creating space for organisations to respond to local needs in their strategies. The extent and pace of change implied by the 10 Year Health Plan demands improving from within, rather than the current over-reliance on external assurance. Defining standards from afar may struggle to keep pace with what’s happening in practice if services innovate and evolve at the speed required. Understanding, supporting and assuring how organisations are managing their transformation and core delivery will be more effective than seeking to define inputs or specific service requirements. Wes Streeting’s commitment to slimming down central targets, empowering providers and systems to innovate, suggests political support for the evolution needed.

Trusting and equipping the hundreds of health sector organisations to reliably deliver their part in the 10 Year Health Plan must be central to the model of change. This will need to be combined with investment in the infrastructure to systematically learn and share between places: while we cannot direct change from the centre, nor can we afford to solve problems in silos. 

The Q Community provides a learning and collaboration infrastructure with the breadth proportionate to the scale of the 10 Year Health Plan: spanning professions, sectors, topics, methods and geographies.  Together with other networks and organisations, we need to dial up our capacity to evaluate, highlight good practice and share this through not just articles, case studies and presentations, but through providing spaces to learn from others on a similar journey: in line with the evidence about how change spreads. 

Reinventing the wheel risks being a criminal waste of resources that we can ill afford.  Making it as easy as possible to learn from elsewhere and signalling more strongly from the top that this is an important and core part of how we operate, will be key to the pace of transformation the sector can achieve. 

Q is a place where people bring together – and practice – skills in mobilising change, share ideas on delivering change programmes and embedding improvement principles into how we deliver as organisations.  We use what we learn to influence the sector to create the culture and conditions in which improvement efforts succeed.  Q’s role in enabling the future is central, learning together about both the what and the how of change over the coming years.