“How can we possibly plan for the next few years?” asked a friend of mine (a director in a NHS foundation trust) during a recent conversation on the challenges facing the health sector. I was stuck for an immediate answer, but I sympathised with her frustration about planning when the future seems so unclear.
Her question stayed with me. Is strategy development impossible in the current NHS or is it an essential leadership task for delivering high quality care?
Many will recall the story of President Kennedy’s visit to Nasa in 1962 when he asked the janitor what he was doing. The man replied, “Well, Mr President, I’m helping put a man on the moon.” I’m confident the vast majority of NHS staff can articulate what they do and how it relates to patients. But I wonder how many could articulate the strategy of their organisation and how it will enable the delivery of high quality care?
Strategy can be described as a set of choices and principles to support the achievement of long-term goals. It includes the allocation of resources and responsibilities, drawing on evidence and setting challenging but realistic timescales for achieving those goals. Robust strategies should draw upon expertise from staff, patients and other partners to guide and inform them so that organisations can adapt to the changing and increasingly challenging clinical and financial environment in which they operate.
That’s easier to say than deliver. Developing organisational strategy is a challenging task for any senior leader regardless of the sector but does the complexity of healthcare make this even harder?
Last year, Monitor commissioned independent research to assess the quality of strategic plans and planning capabilities at foundation trusts. While the review identified some clear examples of good practice, it also revealed that there was significant variation in capabilities across the sector.
In fact, only a small proportion of the sector was able to perform the full range of planning tasks to a high enough standard to produce well-articulated plans aimed at enhancing patient outcomes and addressing any underperformance. In contrast, a large number of trusts struggled with some of the most important planning tasks; and in a limited number of cases, plans continued to overlook long-standing problems.
So, this summer, we’ve worked with five trusts to learn from their experiences of developing strategy in order to co-design guidance and a toolkit to help the entire sector do it better. Each trust faces different challenges and has different opportunities in their local health economies or beyond. However, developing a robust strategy is vital for all in either overcoming those challenges or maximising opportunities. It has been a privilege to learn from the leaders of these trusts and useful in illuminating the difficulties and pleasure of developing a real-life strategy.
But strategy isn’t just about the future, it’s also about supporting boards to manage the here and now. In a research programme between 2010 and 2012, Prof Michael West conducted a study into prevailing culture and behaviours in the NHS. Its findings showed that organisations with unclear and disjointed goals were characterised by tied up resources, ambiguity, fragmentation and competing pressures; they had poor intelligence on which to base decisions/improvements; highly variable staff support; a lack of respect and appreciation and a lack of integration which led to time-wasting, frustrating barriers and gaps in care.
Therefore, while dealing with uncertainty is core to strategy development it should offer an opportunity for innovation and challenge the “way we’ve always done things around here”. Board members have to use their skill and judgement to lead these discussions and to make clear decisions based on evidence to address the challenges facing the NHS.
Rather like the characters in the film The Wizard of Oz (1939), as a senior leadership team sets out on their strategic journey they must have brains (like the scarecrow), heart (like the tin man), find courage (like the lion) and use all of these to best effect to return home (like Dorothy). In reality, there is no Wizard of Oz who has all the answers, and the main resources to deliver a good strategy usually exist within the local health economy. So, the trick is to use them.
Strategy development in the NHS is not impossible but it does require head, heart, courage and ultimately great teamwork.
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