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A shift in mind-set, behaviour and responsibility


Like many people I was shocked by the findings and stories emerging from the Mid Staffordshire hospital trust review published last week. However, there are a number of more subtle issues that I find equally disturbing.

The concept that 300 recommendations for improvement can be prioritised or acted upon coherently by the complex network of organisations and relationships that form the NHS seems optimistic – it begs the question, what are the fundamental guiding principles of this change programme?

More importantly, how profound is the change required? From the emotion and political rhetoric it seems that it’s a seismic shift that’s required, a shift in mind-set, behaviour and responsibility.

Unpacking this, one of the key aspects of the required reform seems to be the critical importance of behavioural and cultural change. Behavioural change – change directed at removing the constraints to good behaviour and incentivising that good behaviour – is deceptively simple and is remarkable in that small changes can deliver extraordinarily large results (see the interview in last weeks Guardian with David Halpern – Head of the Governments Behavioural Insights Team). Behaviour is not a second order problem somehow subservient to a grand intellectual project of reform; it is the change that we are looking for. I know this to be true from delivering 37 projects across local government delivering efficiency and improved outcomes by focussing on changing the behaviour of staff and citizens.

Currently the NHS response is geared towards continual structural change, to changing process and targets, and to sending in private sector corporate recovery teams to sort out failing Trusts; is it any wonder that behaviour and the quality and impact of care is overlooked?

How can we be convinced that the same old players are able to do it? Why will they be able to do it now when they didn’t before? Because processes are easy to model, structures are easy to see, and numbers are easy to count, change has been grounded in these logical terms.

What the existing establishment fail to understand is that doctors, nurses, care managers, patients are all humans – they don’t make logical and rational decisions, their view of personal benefit is driven by their own values system. Until the Government accepts that a new breed of managers need to deliver the next wave of reform in the NHS, and the public sector more widely, unfortunately things will only get worse as the money runs out.

Over the last two years I have seen with my own eyes the management resistance to new thinking. The focus has been on process and targets rather than people and behaviour – this in a system where the average tenancy of a Trust Chief Executive is just over 2 years in post and where consistency of a change direction is difficult to find. To achieve cultural change there must be clarity and consistency of leadership driving clear standards and expectations of behaviour.

What we need is a much simplified system, with a new and independent cohort put in place to drive the cultural and behavioural change required

The theory of change must be rewritten for the NHS to become a sustainable and worthy provider of excellent health care in the future. It needs to understand how to put in place the right incentives to enable people to look after themselves, to identify the right incentives for nurses and doctors to care for people effectively and efficiently, and the right incentives for management to be truly accountable for performance.

12th February 2013

Martin Cresswell is Chief Executive at IMPOWER. To contact him to discuss this blog please email or call 020 7017 8030.

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IMPOWER is an organisation driven by a social purpose. We are a values led consultancy dedicated to the reform of the public sector.



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