Editorial Thursday 1 December 2016: Interview with NHS Improvement chair Ed Smith on 'Developing People, Improving Care'

NHS Improvement chair Ed Smith talks to Health Policy Insight about the new ‘Developing People, Improving Care’ framework

Health Policy Insight: What is the main aim of the new ‘Developing People, Improving Care’ framework?

Ed Smith: Its aim is to change the climate in which over a million people working in the NHS operate, to one that is more inclusive and compassionate. The climate shapes the way we develop, work and collaborate day-in, day-out.

This framework also seeks to change people’s perspectives on how we create improvement skills, and do talent development and training – moving to a view that we should do a lot more learning from each other internally and across organisations, rather than defaulting to going on expensive courses and to events.

HPI: How is it being funded? Is there new money associated?

ES: One thing I’ve noticed in this part of the health and care system is that although the NHS has lots of discrete activities on its leadership agenda, they are generally not part of any common framework.

So I’m not convinced that for now this needs new funding, but the system does need a leadership development framework attaching to one common set of principles. That’s what we’ve worked with and across the sector to produce here.

So if people are asking about money, one thing would be to stop automatically sending people on very expensive courses, whose cost-effectiveness to their employer is opaque and the amortisation of that spend is rapid because of the context of the participant’s workplace.

This needs to be about making much better use of the leadership development funding that we have already across a vast array of bodies - both publicly and privately sourced.

HPI: It’s heartening that this comes with no sign of a new organisation or bureaucracy ...

ES: I believe in instinctive collaboration across organisational boundaries. Interminable reorganisations are wasteful, as we are seeing. This work follows on from the Government’s acceptance of the Rose review and the Smith review: we got NHS Providers, NHS Confederation, NHS Clinical Commissioners, and the Local Government Association to all work together on a common set of principles and early priorities.

With eight health and care arm's length bodies and Skills For Care around the table as well, that co-creation was one of the most joyous things – not being stuck in organisational silos but taking a whole-system approach

HPI: At the Kings Fund annual conference, NHS England CE Simon Stevens spoke about the need to upgrade talent in parts of England to deliver sustainability and transformation plans (STPs): to how many areas do you think that applies?

ES: I just don't know. What we should be doing in STPs is to release the innate talents and constraints we have by improving the way we work together.

What I would say is that we have a relatively low number of people with experience of operating in systems – unsurprising, since many NHS incentives and regulations have been developed to drive people into organisational silos, so people focus on their organisation rather than on common system components - most particularly, patient journeys and outcomes.

Health and care is a complex ecosystem, which must operate beyond organisational boundaries. Until we have lots of leaders with experience of operating across systems – thus our framework’s principle of talent development and aim of ensuring experience across different organisations to help them be able to see the system over their careers through many pairs of eyes.

This programme was developed with sector-wide collaboration, and it started before STPs were launched, but all the principles – those inclusive behaviours across organisational boundaries - come together to focus on patient journeys and outcomes.

This is what we need to reconstruct our health and care system to be fit for the next 20-30 years: we’re not there today, clearly.

HPI: If legislation and regulation drive currently unhelpful behaviours, what do we need to change?

ES: We often find an NHS system reflex has been to impose a new regulation or rule, prioritised over developing leaders and oxygenating organisations to rely on people’s own instincts and natural behaviours. So we have a system that’s bordering on suffocation of organisations, rather than nurturing talent.

If we forget the NHS is about the talented and dedicated people with whom we work with day-in day-out, then it won’t be one that serves our population well.

Of course there’s an important place for rules and regulations in health and social care, both for safety and as critical professional disciplines, but I think we’ve overdone it and created an excessive regulatory reflex.

I also accept that there are rotten apples in barrels, but we should deal unambiguously with those rather than condemning the whole barrels.

In other sectors, I’ve experienced systems allowing people to be innovative and to feel that they can do improvement on the ground and in their work across teams, supported by their leaders: that creates and releases a positive virus. That way, you get a virtuous circle of talent development and contribution; not a head-down, just-doing-my-job approach that’s frightened to change and work differently.

HPI: The framework mentions the need to improve culture: are the other deficiencies more in technical management skills or in leadership qualities?

ES: It’s a mix of both. We’re definitely short of technical improvement techniques, as with the Virginia Mason programme which uses hard technical skills to support improvement. There are many examples of ‘Lean’ being used in the NHS, but one main aim of NHS Improvement is to support the development of a range of improvement techniques, of which 'Lean' is one.

Of course there are healthcare providers who do this well – it’s about improvement and doing things differently being part of the DNA of the organisation. But too many don't have enough internal transfers of improvement skills; never mind a reflex to learn across the system as a whole. It’s far from being as systemic as I would like to see it.

There is certainly insufficient sharing of improvement techniques across organisational boundaries. NHS Improvement is not aiming to be some ‘command and control’ centre of improvement – our role is to facilitate the good work going on, and to point people to it and help share it.

But we have improvement tools and an improvement faculty, with 40 leaders and experts from across health and care communities. We have behavioural experts who can help.

This is not just about the hard technical process management skills: the soft stuff matters too, often more so here - and anyway, doing the soft stuff is really hard in this system!.

HPI: What is at the root of deficiencies in current NHS leaders – the individuals (inputs), the training (techniques), or the system?

ES: The whole system itself is now running so hot that we’ve all gone very short-term, and it just feels like all focus is on day-in day-out service delivery and reducing cost. That focuses people on short-term operational necessities, which are of course important and we cannot steer away from the need to do this. Nor should we be allowed to do so, as there is efficiency to be recycled into better care.

But it's that and more - we also need time to coach the next generations at all levels, and to learn from their good ideas; lift our heads; ensure that successors are identified early and given the space and cover to develop.

We are where we are in the cycle - under intense pressure - but we can break that cycle by applying this dual approach.

But I also think we have made the job of leaders in the system rather unattractive, so that too often, people don't step up – talent hides, or doesn't aspire.

The leader’s job is difficult, but we have made more it difficult than it needs to be.

Another common error is the belief that if we send people off on costly courses, they will return and change the organisation with their new magic wand. That’s silly and wasteful.

Most sustainable leadership development takes place within health and care organisations: we have not done enough to connect the injection of new ideas and techniques from focussed external stimuli with leadership development work locally.

HPI: How have we been making the job harder than it needs to be?

ES: Some structures that have been created mean operating across the health and care ecosystem has become more difficult. Fragmentation is the enemy of collaboration, as much as centralisation is.

We often see the ‘enemy’ as being another component in the health and social care system, rather than being what it really is: an ageing population with more co-morbidity; rising delivery costs; and workforce shortages. That leads to wrongly focusing on the enemy within rather than without – which is debilitating if people are trying to deliver great services.

Rising demand is a huge issue, and if we’re always in short-term mode, then redesigning and reimagining how we deliver care is hard.

The simple shortage of workforce leaves us short of the types of people we need, especially at the clinical level. We also have some deep-seated issues in how we train people via the medical curriculum.

We also lose too many to other parts of the health and social care system in other countries. We need to warmly embrace our native talent, keep our large investment in people in our own NHS for longer and nurture our overseas talent

HPI: With Brexit, that seems tricky …

ES: Yes. Not easy, but the UK has always been a great place for talent to come into our health and social care system and into academic health and care education and research work. It’s essential for that to continue – and I think most leaders from all parts of the health and care system will say that the government has to find way to ensure talent keeps coming in.

Equally, I think we should work much harder on not constraining the supply of talent in this country who would like to work in our health and care system, due to constraints.

So we welcome the opportunity to increase workforce supply domestically. And to stop people leaving – too many just go, and that’s back to my point about making the climate warmer!

We are back to the climate. Oxygenating the system, making people feel they want to come to work – most NHS staff are motivated by a sense of vocation – and if they feel that vocation can't be maximised, they are more likely to opt out.

HPI: Are NHS HR and training efforts unfit for purpose?

ES: This framework will help people think through what types of intervention are necessary, and what need to change to align with the framework principles.

It’ll also reinforce the fact that most important leadership development happens in the workplace, not the classroom. Too many people seem to believe that the answer is sending people off on courses: they believe that alone will create change in the organisation.

Yet there is no evidence that happens if your workplace doesn’t reinforce openness, team development, coaching and improvement day-in, day-out. This starts with the CEO and chair: they set the tone for their direct teams, and as such, the climate for an organisation

It comes down to how we operate within our own organisations. I was very keen for all arms' length bodies' chairs to pledge that we will work on our own organisational climate and style of interaction with the service: all of us as chairs have signed up, which is a good start! The proof of the pudding will be in the eating, of course.

At the organisational level, NHS Improvement are kick-starting work to roll back some regulatory interventions and data requests to create space and our levels of collaboration in particular with NHS England and the CQC are rising substantially, but with further to go.

I feel quite strongly about the tone set by leaders. We don't want people coming up through organisations to feel all they can do is agree robotically with their leaders.

That’s the whole point of this – people close to the ground understand well what’s needed in service environments. They should feel empowered to express that and work on new ways of making it happen. That approach will actually make an organisation’s leadership look better!

Ten years ago, in my ‘Papering Over The Cracks’ report, I set out some questions for leaders: as a leader, how often do you listen to others in your organisation other than your direct reports?

At every conference and hospital visit, I talk to leaders about getting out of their office and walking the floors, like the great retailers of the past. Talk to the public and staff. Get out of the executive suite: in doing so, you’ll find out quite a bit on the climate of your organisation; its people; the spirit; new ways of doing things and other things you won't find in the executive suite.

In most cases, I am of course speaking to the converted - but not always, and it's also the frequency, consistency and resultant action that are important, not just the tokenism of doing walkabouts.

HPI: Where do you see examples of the compassionate and inclusive leadership the framework proposes?

ES: At the risk of sounding biased, of course our own CEO Jim Mackey and colleagues’ work in Northumbria to create an inclusive environment is an example. In Frimley Park as well, and what David Sloman’s doing at the Royal Free. Also in the five Virginia Mason pilots, where values are at the heart of the improvement activities.

Both University Hospitals Bristol and Guys and St Thomas's are great at staff engagement.

And beyond acute providers, East London FT is a great example of the complex interactions of a large mental health trust; as is Birmingham Community Trust on the community provider side. There are some examples of good practice almost everywhere, but rarely across whole organisations, instinctively.

The best places are where this approach becomes 'how we do things round here'. Good leaders recruit in that image – it becomes self-reinforcing. Everyone flocks to work in the places where it’s great to work, and to avoid places where you can smell that the place is not oxygenated to allow staff to follow their vocation to help the sick and care for those who are not going to get better.

That same philosophy applies to our arms' length bodies and government departments as it does across both the wider public and private sectors

HPI: What does the average eighteen-month tenure of chief executives in their jobs tell us about the health and care system environment and the need for this work?

ES: Eighteen months is a time-frame that is self-evidently not consistent with creating a climate of continuous improvement for patient care - or indeed for talent development for any system, let alone one as safety-critical as patient care.

I don’t know how and why that reflex of “succeed in the short term or get shot” has pollinated our world, but we are trying to stem the tide. At the same time, of course, the delivery agenda has high expectations which must be met.

I come back to the point that we have made the job too hard and unattractive. This framework is a 10-20 year endeavour to get to a place where the demanding parts of leader’s job are also incredibly rewarding, seeing talent coming through and bringing on the next set of leaders.

An organisation where self-improvement, peer-to-peer improvement and across the service improvement  is a natural reflex of the people that work in it.

I have also seen over four decades of leaders who oxygenate getting success, but if regulators suffocate, there will be no progress – that teaches us a lesson.

HPI: The NHS seems to have uniquely few clinicians going into management. Is this a ‘chicken-egg’ issue with culture?

ES: It’s interesting, and we must explore why it’s so. It's not a new thing, of course, but it is interesting as a newcomer for me to see such a two-tier service of management and clinicians.

One reason may be that many medical clinicians in particular are often specialists, who like their specialty and like to operate within it, and perhaps it's not clear to them that general management work would be as desirable? In the current environment, I can understand that view. If it’s just eighteen months until you might get defenestrated, what kind of attraction is that?

Again we come back to climate, and to the role of leaders in embracing all the talent in the organisation. As a system, historically I don't think we've done enough clinically-led improvement, which our team in NHS Improvement are now supporting and which is inherent in much of the LEAN work.

Sustainable improvements in health and care are a result of our human ecosystems coming together – patient-led and clinician-led, with management involved as well.

That’s what our 'Developing People, Improving Care' framework is about.