Cultural change that works: a different plan 

The plan exhorts the NHS to work differently. To see that new challenges require leaving old ways behind. It must work better together – and with others. It must be more attentive to its population – and centrally set standards of course. To work faster, harder – but also be happier, less stressed, and just nicer, please.

This is of course the 10 Year Plan (probably). But it’s also any NHS plan; the same words having now been said for decades. The usual remedy to these ills? Tweak a structure here, amend some organisational rules there, throw in a new performance framework for good measure, and hey presto!

So, job done? Sadly NHS history tends to say no. Not because it isn’t absolutely needed, but that something rather crucial is missing in terms of how to achieve it.

Requiring the NHS to work differently requires 1.5 million people to get out of bed and do their jobs in different ways. At heart this is pure cultural change, about reaching into the innards of our healthcare and grappling not just with 77 years of NHS ways, but millennia of how the whole business of treating people in pain has been carried out. Even the founder of St Barts hospital had to get central sign-off first (and he was “right glad” when he got it) in 1123.

It’s this premise that reform is always as relational as it is rational that sits at the heart of how at Kaleidoscope we support change that works.

So if a government genuinely wanted to spark widescale cultural change in the NHS, to – condensing human complexity into mechanical crudity – turn the NHS off and back on again, what should it do? Four things it should consider.

Start with the past 

If you’re genuinely going to do something new, you have to put it in bright flashing neon lights that you’ve learnt the lessons of the past and this time actually is different. The 10 Year Plan has a headstart here. It’s been based on as large an engagement programme as any other, including detailed conversations with thousands of staff (which, to declare an interest, Kaleidoscope supported) on where change has come unstuck before. Coupled with the finest data-set in the world – the NHS Staff Survey – there is no lack of information as to the current experience of all those who pull on an NHS lanyard.

Understand why things are as they are (then don’t forget it)

There’s a funny thing in all these plans. They say the NHS is too centralised, but um, forget to reflect on why the NHS so often ends up in bringing power back to central London. This isn’t a mystery: such issues so closely relate both to the NHS’s mythic foundations and to the very people writing the plan that, as a former policymaker, it’s an exceptionally difficult thing to write.

But it’s possible, at least to begin with. Robert Francis’ report into Mid-Staffs laid out the NHS cultural flaws in great detail, and was fully accepted by all sides. Likewise, this government’s own response to the Infected Blood Inquiry (similarly graphic in its portrayal of the NHS’s failings) begins by saying it “cannot be ignored”.

But the chance of either review receiving much attention in the 10 Year Plan is doubtful. Real change requires both full honesty and understanding, but also an ongoing commitment to act on it.

Have a simple plan

Yes, this is massively complex, and no, we’re not dealing with one organisation, but hundreds. You don’t need to put the NHS together to show its scale: every NHS trust individually is in the largest 0.1% of businesses in the country.

But this makes the necessity of a plan that can cut through all of that, a plan that resonates with the lived reality of staff and gives them hope and credible belief is essential.

This should start with role-modelling from the very top: a commitment that no NHS body would be asked to do something that the central bodies can’t lead the way on.

Then follows transparency: that the fact there isn’t enough money (as will always be the case) is made explicit, and that some things are more important than others.

And finally, a steadfast commitment to align all the points in the direction of the culture you want to see, or as Catherine Harrison beautifully puts it, “focus on creating the conditions that help people do the work of health and social care safely, effectively and with agency, pride and joy.”

To systematically change the way the NHS works requires ensuring every last piece of policy is pointing in the same direction, and kept there for years. Let’s not pretend that it’s easier than that.

Bind your hands

No one likes to say they can’t be trusted. But every time any government has pledged – for example – to avoid micro-management, or eschew structural change, they’ve ended up doing the opposite.

So let’s borrow from the Treasury’s book and have an Office of Health Policy Responsibility. A clear mandate for both the government, and NHS senior leadership, to state clearly what it wants to do, and – most importantly – why it’s in the best interests of patients to do so. Then allow the new Office to very publicly say if they’re on track or not. It’s not foolproof, it can be gamed, but it’s a start at making clear how and why the best of intentions so often flounder.

This all carries a price: operating in such a way in such a political context is extremely tough. But, with the right commitment, it’s doable. And the counterfactual – an NHS that never really changes – leads either to a Service that never manages to meet expectations, or simply no Service at all.