Crafting the roadmap – Strategy in the NHS

Crafting the roadmap

Fortis caught up with Gary Doherty and Tony Mears to discuss all things strategy

Gary Doherty is Director of Strategy at Lancashire Teaching Hospitals NHS Foundation Trust. He first joined the NHS via the management training scheme and has worked in operational jobs in small and large acute hospitals across England and Wales.

Tony Mears, Associate Director of Strategy at Salisbury NHS Foundation Trust, joined the NHS from the UK Space Agency. Previously, he worked in the Department of Health.

These two very different backgrounds bring two different perspectives to strategy roles within the NHS, so how do they approach the task and where do they see the NHS in the future?

Behind the job title

GD: It’s not the easiest of job titles to explain and there’s variation across Trusts – some lead on transformation or have estates as part of their portfolio and some don’t. That’s okay because it reflects where a particular organisation is at.

The notion that Strategy Directors have a magic wand and somehow know the secret answer to all problems is flattering but unfortunately not true. A good plan in one place is a bad plan in another – it always depends on context, which links back to having the right strategy.

TM: Some people believe ‘strategy’ is one thing and it’s the same everywhere, but it really isn’t. It’s different between providers and even between primary, community and acute environments, and different again at system and national level. I think there’s merit in a wider conversation about what we want from our strategy leaders.

The day-to-day

GD: I break it into a ‘day job’ and ‘system’ roles. In the day job, I try to make sure we’ve got a set of strategies that take us to the right place, and a set of plans and an operational annual plan to ensure we will get there. The job is an interesting mixture of external work – taking account of national developments, what people want us to do and think we should be doing, areas where we’re delivering or not – and internal teamwork to, again, work out where we should be going and get people on board.

On top of the day job, I’ve got system roles in a few key areas. I’m the lead for elective recovery for Lancashire and South Cumbria. My other system role involves our commitment to get all four acute Trusts onto the same electronic patient record. We want to converge our operational clinical pathways, digital processes and teams, which is a big piece of work. I’m also doing system work around areas such as pathology.

TM: It varies but let’s look at one recent day. I had a meeting with my counterparts at other organisations about a community services tender that we’re jointly bidding for. I had a one-to-one with the person who looks after our improvement activity. I give him the strategy and he plugs it into our ‘Improving Together’ methodology – that’s how our strategy is deployed. I had a meeting about health inequality funding with the system. I assessed some expressions of interest – we’re taking some external advice on our Stars Appeal charity. And I chaired our board ‘engine room’ – we walk through Trust data to ensure delivery of our strategy.

Making ICSs work 

GD: We moved away from provider/commissioner silos, so there’s more opportunity to do things in a provider collaborative sense and also a system sense. As part of my role as the lead for elective recovery, where we’ve still got some major challenges in terms of reducing waiting times for elective operations, I work with national and regional teams to give a central, unified message. I also facilitate system work to drive mutual aid – waiting lists are longer in some Trusts than others, so we want to offer choice to patients to minimise waits.  We also want people to work together in terms of spreading best practice. Getting the value of working collaboratively at scale versus getting stuff done locally is a balancing act in terms of everyone’s time and effort. You want to get on and do things, but the governance is important, so you loop back to how you work together as Trusts and how you progress decision-making, ensuring you’ve got clear lines of accountability.

TM: My work at the UK Space Agency and in Whitehall was about informal levers and influence – the alignment of objectives and the skills you have to get stuff done without direct control. When I came into the NHS, it was moving from a ‘command and control’ model into this ‘system’ world, so I was seeing senior leaders grapple with this shift. It’s easier for those of us in strategy roles because we’re interested in anchor organisations, system working and the big picture nationally, so we’re predisposed to be more collaborative. Some people will still reject the premise that this is the best way to do things, which is perfectly valid because they’ll have their reasons for believing that.

The challenges

GD: In Lancashire and South Cumbria, we’re asking where it is that we should bring things together and do them at scale and where it is we need that real differentiation, that local approach. Most of our services have probably got a little bit of both. For example, we tend to talk about non-elective care and elective care, but most of our surgeons do both. Several places have a large central pathology processing laboratory and get real benefits from it, but how do you decide what goes in and what doesn’t? The clinicians who work in that service will have their foot in a regional service, but they’re also very much part of their local team.

There are so many variables and moving parts – a healthcare organisation in a local economy is mind-blowing in its complexity and therefore it shouldn’t surprise us that what looks like the right plan in one place doesn’t work in another. No matter what variables you’ve considered when putting your plan together, you must accept that there will be something that you either haven’t thought of or not computed in the right way.

TM: Personally, the challenge is juggling such a varied portfolio and bringing my best to so many competing strategic priorities. More provider collaborations and group models will give those of us in corporate function roles the chance to amalgamate work.

Organisationally, we have three key challenges. Firstly, we have a cancer performance problem, particularly around waits. Secondly, productivity, by which I principally mean the money and system deficits. And thirdly, we have a length of stay beyond the criteria to reside problem. It keeps escalation spaces open in the hospital, drives enormous cost, and patients deteriorate. If we integrate pathways through from care at home, primary care, community care and what needs to come to acutes, we can start to get to grips with that challenge. The answer is not more acute beds, because we’re just creating a national sickness service and we’re supposed to be dealing with the absolute sickest people. Acutes get all the money because we need to put it there, but you can’t lower the day one costs to acute services, so you have to double run for a while, which is fabulously expensive and politically no one wants to do it. But we must do things differently.

Nationally, the challenge is increasing healthy life years. To be clear, I don’t mean life expectancy. There is a decades-long gap between the richest and poorest in this country for how long you can expect to live in good health.¹ At our current trajectory, the government’s stated aim to reduce that to five years will take 192 years.² I don’t see anyone, anywhere getting a proper grip on it. If you can fix that, everything else is going to get better.

Innovation in practice

TM: For a lot of the missions at the UK Space Agency, it’s innovate or die. The NHS has a slightly different problem where it’s failing to adopt good practice rather than invent new things, but the opportunity is bigger in the NHS. Someone’s going to crack it at some point and bring something that’s designed for the 1940s to where it needs to be for the rest of this century. I like the Henry Ford quote: “If I’d asked people what they wanted, they would have said a faster horse.” We need fresh and radical thinking.

Some believe the problems are always the same and they just come in cycles – length of stay, money, productivity, etc. Of course they’re not solving the problems; it’s because they believe that they’re cyclical and so keep doing things the same way. It’s hard to escape the operational pressures of today and ask: what do the next 10 years look like? People are so busy dealing with incredibly overwhelmed and stressed operational pressures, they don’t look up.

All innovation happens at the edges. For example, in my Hampshire Hospitals role, I was looking after innovation for the New Hospital Programme. We asked the space sector: ‘what of your skills and capabilities could be brought to bear for the design and delivery of a new hospital and its services?’ Some of the things that came from that call were world-firsts.³ There was a professor at the University of Southampton who designed a filter for a hospital using thruster plasma from spacecraft – the filter never needs to be changed and instead of collecting stuff, kills it. During the pandemic, those members of staff cleaning and changing filters were losing their lives to Covid-19, so that filter design was tremendous.

Another company looked at taking terrestrial health data that health organisations possess and combining that with space data – air quality, thermal imaging, topography – to create a map that you could interrogate to assess risk of health inequity down to street level.

Key advice

GD: Success comes when you’re able to put forward a really compelling clinical argument for change that resonates with individual patients and staff, their outcomes and experiences.

TM: Try to find opportunities for ‘blue sky’ thinking – we’ll end up in a better place if strategy leaders have thought about what they want the next 10 years to look like. Innovation is not going to happen by doing the same thing repeatedly.

Future-gazing

GD: Our focus has to be on wellness – we want people to be happy, healthy and wealthy. As such we need to work across all sectors to keep people well and to proactively identify and respond to potential ill health before it gets to the stage where wellness deteriorates and people need to access healthcare. This is of course a massive challenge and one we have been trying to overcome for many years. Hopefully going forward technology will help us – whether that be sophisticated monitoring through wearables or technology within people’s homes or their bodies, or through predictive technology such as genome sequencing. The ability to predict future health problems way in advance will be a game changer, but will bring its own problems – if we all knew what our likely lifetime health profile would be, would you still be able to maintain the public support for all citizens paying into an NHS that is free at the point if use? The fact that none of us really know if we’re going to be ill but we know the NHS will be there all of us is a powerful, binding force. It may be tested going forward, but I believe the NHS will keep binding us together. To me, we absolutely need the NHS to be there forever, free at the point of use, bringing our country together. But of course, if you look at the budget pressures and demographics, it’s going to be really challenging. That’s exactly why you need a really good strategy and a plan!

TM: We need strong public trust in the NHS. Otherwise, I can see a future where we’re asking if it should be free at the point of use. According to the Times Health Commission⁴, 66% of people think that the NHS is doing a bad job and 39% of them aren’t sure it will be there for them in an emergency. Thirty-eight pence in every pound government spends goes to the NHS⁵. Would every taxpayer choose that level of prioritisation?

Many think the ICS landscape has settled, but how they are chopped and changed with the move towards provider collaboratives and group models will be interesting in terms of what the strategic aims of providers end up being and what business ICSs finally conclude is theirs to do.

I don’t think the Improvement Agenda will survive contact with the radical change that needs to happen in the NHS – and I say that as somebody who is using an improvement methodology to deploy their strategy and is very happy with how that’s going! But improvement is the incremental optimisation of how we do something, making things a little bit better constantly until it’s really good. However, if you stop and look around, the conclusion most people come to is this isn’t working and we need to do something differently.

Then there’s technological disruption. There are discussions about AI and its role in imaging, but I think AI is going to have a much bigger impact in administrative tasks.

We have an aging population in the global north that is sicker with a decreasing workforce to pay and care for them, while the global south is getting younger. Similarly, climate change – we have the NHS Green Plan, but we need to do more. In Hampshire, we’re working towards a campus alongside the new hospital that will be ‘a centre for population and planetary health’ to create a virtuous loop between the citizens and how they care for the environment, and how that environment is used to generate better health for them.

The NHS is the sixth-biggest employer in the world. If we can’t make a difference to the biggest challenges society faces, probably no one can.

The national picture

Matthew Ward joined the NHS 20 years ago and has held various Director roles spanning Provider operations, Primary Care Trust commissioning and as Chief Operating Officer of a local clinical commissioning group. He is NHS England’s National Strategy Lead, which covers the breadth of the national estates portfolio.

“My role is about looking outward and making sure we are planning appropriately,” he explains. “Our national estates team has some fantastic technical expertise on healthcare estates, but often they don’t have the time or the headspace for forward planning and linking up with key strategic developments either locally or nationally, which is where I come in. Within that, I lead strategic estate planning, oversee our approach to primary care estate and manage NHSE’s transactions advisory. My main focus is to ensure we plan as bottom up as possible, so I spend a lot of time co-ordinating a national programme that is focused on ICS infrastructure planning. This incorporates all aspects of development in the estate, from prioritising capital to estate utilisation and integration projects. It also includes areas that have an impact on infrastructure, such as digital and workforce. Having worked in so many different parts of the NHS allows me to help translate to others the ambitions of our team, key partners and even government.”

So, what does it mean to be strategic in the NHS?

“The key is to push the boundaries where you can, but also work out where you shouldn’t and adopt a different – maybe even tactical – approach. You must work out what’s in our gift to do and what we need other people to do for us, and try to influence and challenge other parties to get there. You’d love to have a blank sheet of paper to do whatever you need, but unfortunately there are often limitations within the public sector.

“Strategy, planning and development can be seen as a bit wishy-washy and secondary to some harder-hitting things. But that’s completely wrong. Getting it right is difficult but, when you do, it puts everything in the correct place. Engaging people and working collaboratively all comes off developing and having a clear strategy.”

Aside from the obvious financial challenges, what does Matthew believe are the key issues facing people in strategic roles at NHS Trust level?

“They need to try and not get sucked into the here and now. Everything’s about waiting lists, A&E attendances, surviving post-Covid-19 – it’s easier said than done, but 99.9% of other people in a hospital are dealing with those things, so it doesn’t need strategic directors to do it. They need to have the confidence to say: ‘My job is to ensure we don’t lose sight of the opportunities, what’s happening around us and the direction from government.’

“There’s an unspecified bit of a strategy job, which is that ability to ask ‘why?’. It can be really hard, but you must do it because there isn’t another role that naturally will ‘challenge and ask’.”

FOOTNOTES

¹ https://www.health.org.uk/evidence-hub/health-inequalities/life-expectancy-and-healthy-life-expectancy-at-birth-by-deprivation#:~:text=In%20England%2C%20women%20living%20in%20the%20most%20deprived,the%20difference%20is%20slightly%20smaller%2C%20at%2018.4%20years]

² https://www.health.org.uk/news-and-comment/charts-and-infographics/healthy-life-expectancy-target-the-scale-of-the-challenge]

³ https://business.esa.int/funding/nhs-future-hospitals-initiative]

⁴ https://s3.documentcloud.org/documents/24398476/times-health-commission_report_2024.pdf]

⁵ https://s3.documentcloud.org/documents/24398476/times-health-commission_report_2024.pdf]

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This article was taken from the May 2024 edition of FORTIS magazine.

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