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The NHS has long struggled…
… not with a lack of good ideas, (the Academy of Fabulous Stuff is overflowing with them) but with the diffusion of good ideas across its sprawling network.
Back in 2000, the NHS experimented with Improvement Collaboratives. Structured programmes designed to spread proven innovations quickly.
Hopefully, they’re being given the kiss-of-life…
… back from the time when they were given the kiss-of-death… and choked off.
Based on the Institute for Healthcare Improvement’s Breakthrough Series, these quality collaboratives brought together teams from multiple trusts to tackle a common problem…
... emergency access, cancer services, or critical care… using shared improvement methods… Plan Do Study Act cycles, and measurement.
At their best, the collaboratives worked. Peer-learning, rapid testing of ideas and local adaptation. Teams had support, visibility, ownership, and license to experiment.
Across participating trusts, measurable improvements in patient-flow, waiting times and care-quality were visible.
The key ingredients;
- curated learning,
- local ownership and
- professional engagement.
People weren’t following instructions. They were actively, co-designing solutions within a framework that encouraged ownership and sharing.
Central government, impatient for quick-wins and uniform standards, shifted to a command-and-control model, dominated by targets, performance-management and league tables.
The NHS Modernisation Agency was dissolved, central funding for collaboratives dried up and the skilled faculty, supporting improvement evaporated.
The rich, iterative learning that had driven real change was replaced by a focus on hitting numbers.
Many of the ideas and processes seeded by the collaboratives were abandoned or reduced to box-ticking exercises.
The targets became the target, not the quality improvement, leading to gaming, cheating and engineering.
This history highlights a fundamental tension in the NHS…
… the diffusion of innovation works best in bounded, coherent systems. Everything the NHS is not.
Change-makers rely on Everett Rogers’ Diffusion theory. It works beautifully in single organisations, where leadership, culture and incentives align, but…
… the NHS is an ecosystem of over 200 hospital trusts, 6,000 GP practices, multiple ambulance services, community and social care interfaces. Each node has its own history, priorities, professional hierarchies and local pressures.
Trying to force national uniformity through centrally imposed targets and sanctions does little to make innovation spread… it stifles it.
Government’s default response to this diffusion problem is targets, threats and penalties… deliver the improvement, or face inspection, financial penalties, or reputational damage.
This breaks all five of my fundamental rules of change management;
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People love change when they feel they are in charge.
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Leaders create the time and space for good people to do great things.
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Patients will experience what the workforce feels.
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Be the best, it’s the only place that isn’t crowded.
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Re-read the first four.
Targets create push-down compliance. They don’t create a climate where staff feel ownership over change.
True improvement requires curation, peer-learning, visible local-wins, celebration and permission-to-stumble on the way.
When the centre relies on coercion rather than cultivation, innovation is stifled, fragile and prone to decay.
The irony is, the principles the NHS may be rediscovering… quality improvement, learning networks, collaborative change… aren’t new.
They’ve always been the holy grail and were being trialled with demonstrable success in the early 2000s, but…
… were abandoned in the rush for uniformity and headline metrics, and...
... in a market driven NHS; competition meant no one would share good ideas and risk losing their edge.
The curse of the postcode emerged.
The NHS doesn’t lack ideas. It lacks an architecture for adoption that respects its complexity, leveraging local-agency and aligning incentives with inherent motivation rather than fear of sanction.
The chronic difficulty in spreading improvement is not an accident. It’s structural, cultural and political.
For real change to take hold, ministers and leaders, must resist the temptation to command-and-control.
We must pay proper attention to the people who do the job and know how to do it, better. They’ll have more traction, be more authentic than anyone else.
The NHS is an ecosystem of the like minded. That can be a good thing and a bad thing.
To make it good… set people free, tell them it's ok to become collaborators, plotters, schemers, wheeler-dealers and disciples of the best. Explorers, in pursuit of excellence.
To make it bad ... easy, just keep doing what we always do...
... suffocate it in guidance.
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