Four principles that could help NHS reform lead us somewhere new?

What a week last week was. I'm really feeling for those working in NHSE, with the uncertainty and worry its abolition brings, as well as how it may impact on the wider sector. Despite this being the direction of travel for a while, in the end it had the feel of a sudden, slash-and-burn move. Compassion, respect and good communications, with clarity on how form will follow function, is essential from here.

With the attention on that seismic reshaping of the landscape, it's easy to miss the emphasis Keir Starmer put on the need for a more agile state. In his various interviews, clearly part of enabling this, he showed welcome recognition of the wealth of knowledge and experience amongst staff working in the public sector, as a rich seam ready to tap into to inform better policy making and improve services. I think I've grabbed onto this as it brings me hope.

I have believed in this for well over a decade, and is why, some years ago, I moved from only advising on NHS policy nationally to also supporting provider trust board members with implementing it in the messy reality of the day to day locally – one strengthens the other. Why? Because context is forever changing and there is always a gap between work-as-done and work-as-imagined, in policy as in everything. Listening, collaborating, showing humility and iterating as you learn what enables, can narrow that gap.

Ultimately, what comes next needs to get us to a place where health and care is working for the benefit of the public and staff within it. Getting closer to the frontline in the way described - in my opinion - will most likely bear this fruit for the NHS if certain things are true:

💡 The coming change brings a new mentality and clear commitment; the national works in service to the local. If so, we have the potential to align practice with intention, but the thought and planning needed to design a system with this result shouldn't be under-estimated. A lot of time and energy has been focused upwards over the years, so it needs to be clearer what is actually a productive balance, and how to achieve it, whilst keeping the overall orientation on patients and local need. For those at the centre, this means believing in the local, letting go, trusting, listening, enabling and learning. Doing this while being held ultimately accountable is not easy, and it's a very human reaction to revert to control. This needs careful thinking through and leadership support to keep to the line, even when things go wrong (which they will).

💡 "Agile" means capable of adaption with the wisdom to know when this is needed, and when not. It shouldn't be about knee-jerk, needless, constant change that uproots existing progress being made and doesn’t account for differences in context. Nor should it be about just "adding to", without stopping what isn't working. National interventions and changes of direction can eat up energy and leadership time, derailing work that needs time and stability to generate improvement. Knowing how to be agile and where, learning and sense-making together, and what pace the national should move to support and sustain improvement locally (rather than shift to the next new idea just as the last is being operationalised) is important.

💡 The centre is clear on the boundaries between its role and others, adding value by doing what cannot be done locally. It’d be a mistake to expect to run things day to day from the centre. Power could now be devolved closer to people who experience and deliver care - the national in service to the local in action. Accountability and attention should be weighted outwards, to the local population, not only upwards.

💡 Policy making is designed to be adaptable. I (nerd-alert) came across a book that struck me as thoughtful and practical in terms of how we better prepare for the challenges of public management today: Creating Adaptive Policy: A guide for policy-making in an uncertain world. Drawn from research, it outlines seven tools that could help policy to adapt to anticipated and unanticipated conditions: Integrated and forward-looking analysis; Multi-stakeholder deliberation; Automatic policy adjustment; Enabling self-organisation and social networking; Decentralisation of decision-making; Promoting variation; Formal policy review and continuous learning. I’d like to know of other frameworks that pull together evidence and set standards so do share. But regardless, it seems to me all of us working in and around policy making should be talking more about what good looks today like in the ‘how’ as much as the ‘what’, given the dynamic nature of the world.

I'd like to think an approach that puts these into action would ultimately help with how strategy is developed and how the operational model comes together, as well as how the NHS is managed, supporting an asset-based mentality and capitalising on the ton of commitment, skill and knowledge in the system. But what do you think? I’d love to know if these resonate or whether your experience leads you somewhere else – do share so I can learn from you. Either way, the forever optimist in me is hoping last week’s moves were not just more of the same but the start of something new.