Innovating Healthcare

Front matter

INNOVATING HEALTHCARE

THE ROLE OF POLITICAL, MANAGERIAL AND CLINICAL LEADERSHIP

John Storey and Richard Holts

Contents

List of Figures vii

List of Tables ix

Preface xi

Preface

The aim of this book is to examine how the many challenges of healthcare can be met. This requires a clarification of the nature and scale of the challenges, and the range of actual and potential responses. In particular, we focus on the contribution made by different forms and levels of ‘leadership’ to the process of innovation. In healthcare, such leadership tends to derive from a range of sources: clinical, managerial and political. We examine all three — and, most importantly, their interrelationships. Recognition of the importance of the different levels shaping healthcare (macro, meso and micro) is not new (see e.g. Robert et al. 2011), but studies which range across and specifically focus on the interplay between the levels are rare.

So, while we look at strategic leadership as a means to innovate in healthcare, we do not restrict our remit to that level. We also bring into the frame the activity of agents at the operational/practice level and at the intermediate levels, such as networks and organisations. Leadership is a contentious concept, often conjuring up ideas of heroic individuals. We find it necessary to include distributed and collective forms as these are readily evident within health services. In tune with this, the processual nature of political, managerial and clinical leadership is to the fore in our analysis. This means that we bring into focus actions and reactions as the central dynamics to be understood. The sites of activity extend from national policy-making forums through to regional and organisational decision-making bodies and on through to activity at the micro and practice levels. The ways in which each of these influences behaviour in each of the others is a crucial part of the story.

A key theme in contemporary reform programmes, especially in England, is a shift in focus from organisational leadership to ‘system leadership’. This latter refers to the demands on leadership to develop cross-boundary formations, such as the emerging integrated care systems, covering populations of approximately 1 million people. Strategic thinking and collaborative working appear to be capabilities which are at a premium here.

The book is not an exercise in abstract prescription. Recommendations and guidelines are offered, but these are derived from empirical xii Preface research on real attempts to lead innovation. That research, in turn, was based on the reading of an extensive literature and upon the use of relevant theory. The core of the book is based on a close study of events at the multiple levels of national policy, organisations, networks and clinical practice.

The analysis focusses most especially on the UK NHS - and upon the English NHS most of all. However, it is informed by a consideration of the wider context of healthcare across many countries and the lessons learned from similar attempts to meet the challenge of innovation. The NHS itself is an especially fascinating focus for study. As has been noted, it can be seen as ‘a case study of conflicting values in the design of social policy’ (Klein 2013: vii). From our empirical studies, we have found this to be a highly pertinent observation, and it helps to inform understanding of the many twists and turns in the story of change in that system of care. Moreover, Klein goes on to observe that, ‘if the NHS is a laboratory in which the micro-politics of a specific policy arena can be studied, it is also an example of how macro-politics can reshape an arena’ (Klein 2013: viii). Our successive research projects underline the wisdom of this statement. An essential feature of the case examples of attempted change which we report in the chapters which follow is indeed the interplay, tensions and gaps between micro- and macro-politics.

Leadership has repeatedly been advocated as a critical part of the solution to the many healthcare challenges. Clinical leadership has been emphasised by many as especially vital. To cite, for now, just one example, the Nursing and Midwifery Council identify it in their Code of Practice as a necessary component of nurse and midwifery training (Nursing and Midwifery Council 2019). We seek to examine and scrutinise what these kinds of assertion mean in practice.

In order to help progress the 2019 Long Term Plan (NHS 201 9a), the government has pledged special funding for ‘system leadership development’. This focusses on a phalanx of future leaders, including general practitioners (GPs), consultants, therapists, social workers and managers. The idea is to grow ‘a cadre of system leaders [to] deliver integrated care at the coal face, building a pipeline of future leaders through mechanisms such as talent management, getting more people into leadership learning courses at all levels in a system, and creating networks of people with interests in leadership development who can inspire others, share learning with peers and problem solve’ (NHS 2019b; p. 3).

The interpretations and insights offered in this book derive from multiple research projects which we have conducted over the past two decades. Most of these projects were conducted in the NHS and funded by the National Institute of Health Research (NIHR). That cluster of projects focussed on related aspects of governance, organisational reforms and leadership — with special attention being paid to clinical leadership and its interface with managers, administrators and policy-makers.

Preface xiii

Importantly, that core set of health service-based research projects was supplemented and enhanced by other research that we conducted in other industry sectors. The projects were concerned with innovation, knowledge, operations, workforce issues and supply chain management. These projects were funded by the Economic and Social Research Council (ESRC) and the Engineering and Physical Sciences Research Council (EPSRC). We have found it invaluable to locate the issues and organisational activities of the NHS within the wider context of lessons learned from other industry sectors.

Drawing upon these multiple sources, this current volume sets out to shed light on the nature and scale of the problems facing the NHS and other health systems, to describe the policy initiatives designed to drive ‘reforms’, to compare and contrast these formulae, to illuminate how actors within the systems respond, to reveal the obstacles to effective change and to show examples of more successful engagement with innovation in healthcare, even in spite of the difficulties. This last issue is, for us, the most central theme because, in casting a light on these promising instances, the processes involved in bringing about effective change are most sharply revealed. The latest far-reaching and ambitious reform in the NHS is to be found in the NHS Long Term Plan (NHS 2019a). This is based on ‘a new service model’ involving a boost to out of hospital care, the removal of the historic divide between primary care and community health, a new emphasis on utilising the potential from digital technologies, greater personal control, personalised care and an emphasis on prevention and renewed focus on population health and integrated care driven by new Integrated Care Systems (ICSs).

These various constituent elements, underpinning the Long Term Plan (e.g. the out of hospital focus, personalised care, utilising digital potential and integration), are not entirely new, and some of them have been around for some time. What would be novel is if, as a package, they were genuinely pursued with vigour and in a sustained way. Notably, some new institutional forms are proposed, including NHSX (a new organisation for digital, data and technology) and the ICSs.

However, our research suggests that a great deal rests not only on the merits of the ideas and the plans but also on a range of social processes, such as the extent to which actors throughout the system trust, and believe, that the priorities and ideas will be acted upon, sustained and followed-through on; how the initiatives are funded and how they sit alongside (or above or below) existing themes, priorities and institutional practices; and how the unfolding innovations are interpreted as congruent with, or threats to, established interests. As noted above, there is rarely a smooth transition from policy to implementation because power and influence is distributed; multiple agents are involved in multiple processes; actions are met with reactions; and the multiple sites and domains of activity mean that identification and commitment xiv Preface to a profession, a unit or a network can be problematic and shifting. One consequence of this complexity is that top-down strategic plans are vulnerable to multiple contingencies so that implementation can by no means be taken for granted.

Accounts of the early days of the NHS, from its inception through its early years, from the late 1940s and throughout the 1950s onwards, reflect a whole array of the issues and dilemmas which still preoccupy the contemporary system. These include the role of the centre vis-a-vis localism; methods and levels of funding, and how to control costs; questions of voice and representation, especially for doctors; and the split between local authority health services and the centre-led medical services. The precise representation of these recurrent dilemmas and tensions emerges in new forms, but the underlying issues remain as evidently very similar, if not indeed essentially the same.

The central theoretical strand followed in this book draws upon institutional theory. Within that theoretical stream, ideas relating to ‘institutional logics’ were found to be useful to help in understanding the dynamics and difficulties encountered by so many well-meaning players we met within the health services. Notions of ‘competing logics’ and ‘dominant logic’ proved useful in making sense of patterns of action and reaction. To drive forward with an innovation — especially if that is in the form of a service redesign — is to pursue a vision of an alternative formula or arrangement. Such forms are usually an expression of some logic. These logics can be at odds with each other, and this causes extra problems for those people seeking to lead change when they encounter not only prevailing extant logics but alternative competing logics and interests.

A senior health academic has noted that ‘how we go about innovating in health and care systems is often pretty chaotic, while the opportunities to find out what works, and to learn and improve from this insight, are too frequently missed’ (Walshe 2019). He further observes that

NHS leaders - along with think tanks and other national organisations with a lot of influence — are dedicated followers of fashion. Devolution and integrated care this year, hospital chains before that, GP commissioning a few years ago, foundation trusts and the purchaser-provider split a while before — innovations come and innovations go.

The merits of consistency of purpose are thus neglected. The NHS is not helped by the way it tends to ‘rush into each new idea with great enthusiasm and an often misplaced sense of urgency... And after a year or two, things move on — or rather, the people who led the innovation initially have often moved on’ (Walshe 2019). This observation resonates strongly with our conclusions, drawn from a succession of studies. It captures the point that particular reform conceptualisations are often

Preface xv closely associated with specific individuals or groups, that is, persons sometimes labelled as ‘leaders’.

Each project we conducted seemed to highlight the need for the next as key issues were identified and surfaced. The data generated derived mainly from face to face interviews with a full cast of actors: doctors, nurses and other clinicians in hospitals; hospital managers and members of boards and governing bodies; doctors, nurses and other clinicians in primary care and community settings; managers and others in the organisations, including practice managers and lay members of primary care boards and clinical commissioning groups; and policy-makers and policy managers in the NHS across a range of institutions, including, for example, the Department of Health, NHS England and local and regional bodies.

Interviews were usually recorded and transcribed. These transcripts were subject to close analysis by members of the research teams involved in each project. This qualitative data was supplemented, in most of the research projects, with more quantitative data derived from surveys. The surveys were conducted using both postal and online questionnaires, complemented by an extensive use of telephone-based surveys. The mix of close-up, detailed qualitative data and larger-scale quantitative data proved valuable. The former approach allowed us to dig deep into informants’ assumptions, expectations, implicit theories, fears and hopes. The interviews enabled insight into actors’ own interpretation of key problems and which initiatives were being tried or had already been tried in order to attend to the problems, and with what outcomes. This data shed light on which players were influential and what specific actions they had taken, based on what plans. This research resulted in rich insight into rival (competing) logics-in-use, conflicts and conflict handling strategies. It produced fascinating stories about plans, reforms, rivalries, resistance and modes of collaboration. To complement this body of data, the survey data allowed us to gain a sense of proportion — to assess the extent to which practices and initiatives were widespread or restricted.

We are obligated to many people, and we are happy to acknowledge our debt. First, and foremost, to the staff of all kinds working in the NHS. As our approach to research in health has always tended towards a multi-level approach, we have relied on the goodwill and cooperation of health workers of all kinds, from frontline practice level staff on hospital wards and doctors in General Practice surgeries through to medical and managerial staff running healthcare organisations at both divisional and corporate levels, and on to local, regional and ultimately national level agents, both clinical and nonclinical, managerial staff and policymakers. Sometimes the occupational identities of the agents merge: for periods of time at least, managers and policy-makers may be clinicians who have either been seconded or moved across into these leadership roles. We have been fortunate to benefit from the cooperation and assistance of each.

Taylor & Francis Taylor & Francis Group http://taylorandfrancis.com

Abbreviations

Accountable Care Organisation

Better Care Fund

Clinical Commissioning Groups Community Health Councils

Care Quality Commission Commissioning for Quality and Innovation Clinical Senates

Commissioning Support Units Department of Health and Social Care Fund Holders

Faculty of Medical Leadership and Management General Practitioner

Health Authority

Health Maintenance Organization Health and Wellbeing Boards Integrated Care Organisation Integrated Care System

Joint Health and Wellbeing Strategy Joint Strategic Needs Assessment Local Authorities

Leadership Qualities Framework Multispecialty Community Provider Multidisciplinary Team

Local Clinical Network

Local Medical Committees

National Clinical Advisory Team National Health Service

NHS Clinical Commissioners

NHS England

NHS Trust Development Authority National Institute for Health and Care Excellence National Institute for Health Research Primary and Acute Care Systems Practice-based Commissioning xviii PbR

PCGs PCTs

Abbreviations

Payment by Results

Primary Care Groups

Primary Care Trusts

Professional Executive Committee Quality Outcome Frameworks Sustainability and Transformation Plans Transaction Cost Economics

Total Purchasing

Total Purchasing Pilots

The challenges facing the provision of healthcare are shared, and well known, across many economies. Demand for services outstrips supply, and there is a workforce crisis, especially notable in General Practice (Britnell 2019; Owen et al. 2019). People are living longer with multiple and more complex health needs. Yet at the same time, social care and community care budgets have been reduced (Humphries et al. 2016). There are large, unwarranted, variations in practices and outcomes, rising costs and numerous examples of failures (Porter and Teisberg 2006). There are fragmented services and poor communication between the component parts (National Collaboration for Integrated Care and Support 2013). International studies of healthcare based on systematic reviews of available evidence across multiple countries find some common patterns in the contemporary challenges facing leaders and managers. These include rising demand, epidemiological shifts, performance issues, and resource and workforce issues. These challenges are met with health sector reforms built on innovation attempts and collaborative initiatives (Senkubuge et al. 2014; Figueroa et al. 2019). Likewise, the leadership and management challenges arising out of the severe workforce shortages globally have been well recognised (World Health Organization 2016). Not surprisingly, many reports conclude that transformational change is urgently needed (Murray et al. 2018). Likewise, the proposed solutions, such as devolved responsibility (Spain and Italy), an emphasis on patient choice (Germany, Netherlands, Sweden), experimentation with insurance-based Accountable Care Organisations (USA) and an emphasis on the need to bolster and even switch from acute care to primary care can be found across numerous countries (Ham 2009; Klein 2013). Indeed, NHS England has stated its plan to use the next several years to ‘make the biggest national move to integrated care of any major western country’ (NHSE 2017, p. 31). The new models of care designed to deliver on this plan are based on the themes of Accountable Care Organizations (ACOs) and Integrated Care Systems (ICSs). A common refrain among all of these solutions is the importance of ‘leadership’ and most especially, clinical leadership (King’s Fund 2018). This is seen as especially vital at a time of simultaneous resource constraints and rising demand

(Maguire et al. 2016; National Audit Office 2018). Furthermore, it has been claimed that leadership can help meet the innovation challenge which stems from the ‘productivity imperative in health’ (McKinsey & Co 2019).

Thus, few doubt that there are huge and pressing innovation challenges that will need to be met if healthcare is to continue to meet demand. And, further, there is a widespread view that (a) innovation going beyond business as usual is needed and that (b) in order to deliver such innovation, ‘leadership’ (in a variety of modes) is crucial. As we will show, this has indeed become a standard refrain in official policy documents. There may be much to commend in such an approach, though a degree of caution is warranted as the widespread appeal to the discourse of leadership as the apparent ‘answer’ to many public sector problems needs to be assessed somewhat critically (Storey 2004a; Martin and Learmonth 2012). The call for wide, distributed involvement in leadership may be a rhetorical device, or it may be an expression of a more genuine intent to spread power and influence in joint problem-solving. Which of these a particular instance may be, and using what processes, we see as requiring close empirical investigation. The fact that it is a popular, if not indeed a dominant, narrative does not preclude the possibility that, in some circumstances, it may accord with a local reality.

In this book, while looking outwards to a number of varied international systems, the main focus is on the NHS in England. In that 70-year-old system, the challenges have been numerous: most notably, trying to keep pace with ever-rising demand, the problems in finding sufficient resources (financial and staff), resolving tensions about sources of funding and tensions about allocation, to name just a few. A survey by the Oxford Academic Health Science Network of the innovation priority requirements currently facing the NHS identified four main ones: workforce challenges; mental health challenges; patients with long-term complex needs; and the effective use of digital and artificial intelligence technologies (Academic Health Science Network 2019).

The proffered innovations and reforms to meet these kinds of challenges have been many and varied. They include, most notably: the introduction of competition and choice; devolving responsibility to local level; introducing management and managers into the system; and, of central interest to our analysis here, placing power and influence into the hands of doctors and other clinicians; and riding high currently, the idea of ‘integration’. Indeed, to take just one example, the Sandwell and West Birmingham Hospitals NHS Trust declares as its central vision: ‘to become renowned as the best integrated care organisation in the NHS’. This includes innovation in taking over a number of General Practices, thus breaking down the traditional primary/secondary care divide. Sitting behind each of these attempts is the suspicion that healthcare organizations are inherently very difficult to change because of a set of forces including, most notably, complexity, professional resistance and, often, the lack of incentives to change (Ovretveit 2000).

Few of the solutions are entirely new, though a remarkable characteristic feature is the ability of political reformers and others to present recycled ideas as if they were original. A more accurate depiction is that the history of the NHS, and to a degree, many other systems, is a fluctuation from one set of solutions to another and then back again or partially so. Indeed, the argument in this book is that the NHS, from the outset, was built around a set of tensions and that these have persisted through time while being replayed and retackled from time to time. Hence, for example, in a national system, who would/should exercise power: elected politicians, professional managers or clinical professionals? Incidentally, in using the term ‘clinician’, we of course refer to doctors, but also to other qualified professionals such as nurses who are registered to treat patients. Hence, in addition to doctors and nurses this includes, for example, occupational therapists, paramedics, physiotherapists and radiographers. The wider term is important in the context of the theme of this book because many of the changes underway involve shifts in responsibility across professional boundaries. But boundaries are not clear-cut because social workers, for example, are involved in many of the cross-boundary, integrative care, innovations discussed in this book, but they are not ‘clinicians’ in the usual sense.

The latest (bold) innovation as outlined in The Long Term Plan (NHS 2019a) is described as a ‘New Service Model for the 21st Century’. It sets-out the key ambitions for the service over the next ten years and it builds on the announcement by the Prime Minister, in June 2018, of a new five-year funding settlement amounting to a headline figure of an extra £20bn. This equates to a 3.4% average real-terms annual increase in NHS England’s budget between 2019/2020 and 2023/2024. To justify this funding, national NHS bodies were asked to develop a long-term plan for the service. Over the previous five years, the annual increase was closer to just 1%. The plan builds on the policy platform laid out in the NHS Five Year Forward View which emphasized the need to integrate care. This was followed by subsidiary strategies, covering General Practice, cancer, mental health and maternity services, while the new models of care outlined in the Forward View have been rolled out through a programme of ‘vanguard’ sites.

Despite the emphasis on integration, local authority social care is still not included. The plan places a priority on certain conditions: cancer, cardiovascular disease, maternity, mental health, stroke, diabetes and respiratory care. In line with the Forward View and the General Practice Forward View, improving care outside hospitals is one of the headline commitments in the Long Term Plan (LTP). The spending commitment to support this theme is that by 2023/2024, funding for primary and community care will be at least £4.5 billion higher than in 2019/2020.

Their share of NHS spending should thereby increase over the period. General Practices are joining together to form Primary Care Networks (PCNs), that is, groups of neighbouring practices typically catering for 30,000 to 50,000 people. Digital services are to be enhanced including access to GPs online and by phone. Alongside PCNs, the plan commits to ‘fully integrated community-based health care’. This will involve developing multidisciplinary teams, including GPs, pharmacists, district nurses, and allied health professionals working across primary care and hospital sites. At the heart of the PCN concept is GP collaboration so that primary care services can be offered at scale, offering a wider range of services. These are envisaged to include structured medicine reviews, social prescribing and more personalised care. PCNs are to be the delivery arm. New money will be channelled through PCNs using directed enhanced service contracts (DES). These will include payments for additional types of staff such as clinical pharmacists, physician associates and community paramedics. PCNs are accountable, via their constituent GP practices, to their Clinical Commissioning Group (CCG). Hence, despite the significance of the institutional shift, there are not to be any new statutory bodies, instead, the reforms are being managed through incentive payments.

To help deliver on the vision/plan, a new institution was created in the Spring of 2019: a new ‘NHS Assembly’. The Assembly has around 50 individuals drawn from national and frontline clinical leaders, patient leaders, staff representatives, health and care system leaders and voluntary, community and social enterprise sector leaders. In tune with contemporary thinking, the idea of ‘representation’ is avoided and the members are most decidedly ‘individuals’ who ‘will bring their experience, knowledge and links to wider networks to inform discussion and debate on the NHS’ work and priorities’ (NHS 2019b). The LTP has its own website: www.longtermplan.nhs.uk/ (accessed 4/3/19).

The plan is interesting in as much as what it does not say as for what it does. Unlike the Lansley White Paper, Liberating the NHS (2010), which emphasised the merits of competition, and commissioning from a diversity of providers, the LTP makes hardly any reference at all to words like ‘market’, ‘challenge’ or ‘competition’. When it does, as in the extract below, it does so in order to move in the opposite direction.

The changes set out in this Long Term Plan can generally be achieved within the current statutory framework, but legislative change would support more rapid progress. The Acts of Parliament that currently govern the NHS give considerable weight to individual institutions working autonomously, when the success of our Plan depends mainly on collective endeavour. Local NHS bodies need to be able to work together to redesign care around patients, not services or institutions, and the same is also true for the national bodies. And the rules and processes for procurement, pricing and mergers are skewed more towards fostering competition than to enabling rapid integration of care planning and delivery

Such reasoning amounts to explicit self-critique of previously prevailing logics. Indeed, it represents an 180-degree turnabout in policy.

The key point for our analysis is that high-level political leadership sets the frame and tone for the exercise of leadership at all other levels and other parts of the service. Its influence is exercised in multiple ways: through the selective allocation of resources, through patronage and appointments, through bolstering of the message by means of regulatory, administrative and managerial apparatus, and ultimately, if required, by statute and other orders.

But the political leadership component is not always so decisive. As has been noted elsewhere (e.g. Klein 2013), governments for the first few decades of the NHS tried to govern through exhortation rather than command and control. The history of the NHS is replete with examples of the exercise of power and influence by other players most notably, medics, local authorities and managers. The numerous attempts to reform, govern and manage the service have involved a tension between competing forces, interests and ideologies. The constant turmoil and changes stand as testimony to the inadequacies, incompleteness, instability and imprecision in one set of vaunted solutions after another.

As has sometimes been recognised, in practice, healthcare is an outcome of action at multiple levels: macro-, meso- and micro-systems (Robert et al. 2011). The macro-level includes national policy-making, the allocation of finance, regulation and accreditation. The meso-level, which includes organizations, such as hospitals, exercises influence through corporate strategies, structures, processes, cultures and practices. The micro-systems level, which includes clinical teams, impacts care as a result of inter-personal communication, professional practices, routines and competences.

The innovation challenges are met with sets of actors and institutions which are in constant tension. The key actors examined in this book are the policy leaders, the managerial leaders and the clinical (mainly doctors but at times also nurses and other qualified professional practitioners). In our view it is necessary to consider all of these together. These agents are not necessarily at odds in total; the differences normally exist within a broad consensus. That consensus in the case of the NHS has been one of universal coverage, service based mainly on need rather than ability to pay, and therefore largely a tax-funded system mainly free at the point of consumption. Within the frame of that broad consensus exist multiple points of difference. From the inception of the NHS, and in the years of design which preceded it (and proceeded it), disagreements and sectional interests were accommodated rather than resolved. Thus, General Practice was located out-with the hospital system, medical interests were given representation on key bodies and local authorities were allocated responsibilities for community health and public health.

In consequence, leadership is required to fill gaps and inadequacies in the formal system as well as the leadership needed in order to make broad principles work in practice. Leadership is required at multiple levels. It is needed to help formulate policy and it is needed for implementation of policy. To put this point another way, in the sphere of healthcare, leadership is crucial from policy through to practice (Barr and Dowding 2019).

There is no perfect solution for the design of a health system (Britnell 2015). Rather, there are tensions between alternative principles and preferences, best described, in our view more neutrally, as ‘competing logics’. These come in a number of forms.

First, there is the logic of a unified, comprehensive, national service funded by taxation and free at the point of use. This might be considered the gold standard notion of the NHS as launched in 1948. But, from the very start, even that ‘pure’ model had to accommodate competing pressures and conceptualisations. Would all healthcare facilities and all staff be fully absorbed into the system? How would the system be governed? What would be the role of the central government in such a nationalised industry, and how and to what extent would it be held accountable by Parliament?

An alternative, and indeed competing, logic contends that efficiency and innovation would be better achieved by introducing challenge, choice and competition into the system. This would require a diversity of providers on the supply side, and the enabling of choice on the demand side. Each of these main competing logics (hierarchy versus market) requires its own set of underpinning mechanisms and tends also to engender its own set of dilemmas. Thus, for example, the national hierarchy model requires a bureaucracy to transmit and administer policies which might aim to achieve universal standards of care across the whole. The parts of the system need to be held to account in some way, and this tends to result in a hierarchy of governing authorities. Inherent questions and dilemmas accompanying this solution include how much power to accrue to the centre and how much autonomy to devolve to the frontline (and to various levels in between)? How will innovation be encouraged and complacency be avoided?