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Why Nick Clegg's implementation of the NHS reforms worked (in his own party)
To give Nick Clegg credit, his implementation of the support for the NHS Bill in his own party succeeded. Aside from the numerous articles written elsewhere about the substantive issues of the Bill now as amended, I should like to explain why selling the Bill to his own party worked. I will also briefly discuss the consequences.
Nick Clegg is an odd type of leader – fundamentally he is charismatic (his popularity figures always remain surprisingly high), and he is indeed transformative (in that he has achieved some noteworthy successes such as ‘the Pupil Premium’). He has been able to ‘sell’ some very difficult policies to the Liberal Democrat Party, but an unfortunate characteristic is that people tend to give him no credit and all the blame (the opposite pattern to Steve Jobs, whose failure over Apple TV is rarely remembered.)
‘Strategic change’ is a key issue studied in great detail in many MBAs, the one at BPP Business School included. Books have been written about complex strategic change, and there is no doubt that the implementation of the actual NHS reforms (already started) will result in failure. This is primarily because it has failed to take into account the current structures and culture of the NHS, including the views of the key personnel within it (including the majority of doctors and nurses).
However, Nick Clegg got the support of a key follower, in this case, Baroness Shirley Williams. She is a good choice as she is a former member of Labour, and the assumption is that she would be fiercely defensive of the NHS as an organ of the welfare state. Nick Clegg was therefore very shrewd to get her support, and, with the help of trying to communicate effectively why he felt the amendments were sufficient, was able to get support from his party members. The support of the ‘lead follower’ is an important factor in follower support, and, is for example very important if you are seeking adoption of an innovative problem or service.
Unfortunately, the issue now is what Nick Clegg will have achieved by all this. Left-wing voters are likely to desert the Liberal Democrat Party in droves, meaning that Lab-Lib marginals will almost certainly go Labour. The thorny issue is what happens in Tory-Lib margins; it is very likely that the Tories will win these seats, particularly if Liberal Democrats lose some of their core support. In Tory-Lab marginals, the issue is equally complex, but this could be impacted by a number of factors, including the perceived performance of the economy in 2015; currently it is felt that the deficit will not be paid off until 2017/8 at the earliest because of the very poor level of growth in the UK economy. Conversely, the US economy is now doing very well, as a result of the fact it embraced the importance of fiscal stimulus, and did not reject textbook Keynesian economic theory. Whichever way you look it, it is still possible that the Tories might win with an enhanced majority. However, also, whichever way you look at, while Nick Clegg will have finished a term as Deputy PM by 7 May 2015, the Liberal Democrats are likely to be obliterated electorally in 2015. This presumably does not matter much to Nick Clegg, as his proposals for a reformed House of Lords are likely to fail too.
@legalaware
Blindness to the evidence-based change management advice from the NHS' own unit
Of course, the Government was free to consult any number of management consultancies about how to implement this complicated strategic change management. A recent ‘Mail on Sunday’ investigation based on hundreds of official documents disclosed under the Freedom of Information Act, has revealed the full extent of McKinsey’s links to the controversial Health and Social Care Bill. This newspaper alleges that many of the Bill’s proposals were drawn up by McKinsey, and outlines a number of other specific allegations. The irony is that the NHS has its own specialist unit which produces excellent advice about how to manage change in the NHS.
The NHS has in fact a specialist ‘Institute for Innovation and Improvement’. which is geared up to conduct change management throughout the NHS. Most independent experts feel that the way in which this strategic change has been implemented has been a disaster, and whoever advised on it does not appear to have acknowledged the advice from the NHS’ own change management unit as given on this webpage by Dr Helen Bevan. According to elsewhere on the website, “Helen has led change initiatives at local and national level which have created improvements for millions of patients. Her current role is to keep NHS improvement knowledge fresh, relevant, impactful at the leading edge.” It appears that the unit is heavily influenced by a paper from Harvard Business Review in October 2005 by Sirkin, Keenan and Jackson entitled, “The hard side of change management”.
Here are specific sections of Dr Bevan’s views on change management, and you can easily see why the NHS reforms will run into disaster.
The first factor is duration. An underpinning belief in many NHS change programmes is that we need to execute change quickly. Not necessarily so, say the authors. What really matters is having formal, senior management-led, review processes. A long project that is reviewed frequently and effectively is more likely to succeed than a short project that isn’t reviewed. The second factor is performance integrity. This means selecting the right mix of team members to deliver the change; the most results-orientated people with credibility and influence and effective change skills.
Today, a summit was held where a number of key stakeholders were not even invited. including the Royal College of General Practitioners, Royal College of Nurses, British Medical Association, Royal College of Psychiatrists, and the Faculty of Public Health. As Ben Goldacre has alluded to on his secondary blog, there appears to be a good correlation between those who were not invited to the emergency summit and called for the NHS Bill to be dropped. A recent headline in the Telegraph has provided, “Prime Minister David Cameron today insisted he was “committed” to pushing through the Government’s reforms to the NHS, as he met healthcare professionals in Downing Street.”
The next factor is commitment. The authors focus on two critical categories. There must be active, visible backing for the change from the most influential senior leaders. They say that if, as a senior leader, you feel you are talking up the change initiative at least three times as much as you need to, your organisation will feel you are backing the transformation. In addition, the change is unlikely to succeed if it is not enthusiastically supported by the people who will have to operate within the new structures and systems that it creates. Staff need to understand the reasons for the change and believe it is worthwhile.
This change does not have the backing of the majority of doctors and nurses, and there is absolutely no sense that the medical profession is backing this change. In fact, this BBC webpage gives details of who stands where on the change, and many professional bodies would like to “kill the bill”.
When an issue matters so much to the public, why has the Government accidentally or wilfully turned a blind eye to sound change management advice from its own unit?
The NHS reforms: the problem and the solution
I have a personal interest in the NHS. Aside from qualifying myself in medicine from Cambridge and doing a few years as a busy junior doctor in Cambridgeshire and London, my late father was a GP for three decades near Brighton. Furthermore, I owe my life to the NHS, as I became unconscious on June 1st 2007, due to bacterial meningitis – I woke up from a coma in the middle of July that year thanks entirely to the brilliant staff of the Royal Free. Through a diverse academic route, I came to complete a MBA last year at BPP Business School. Indeed, the case study for the organisations and leadership module was a case of change management in the NHS. I obtained 84%, and the pass mark was 50%.
To me, it’s clear what the problem is. Now is not the right time for the Government to have immersed itself in such a complicated strategic change management, when the country is doing extremely poorly. Indeed, only this morning the Bank of England confirmed missing its lending target to small businesses, and two surveys were published suggesting this morning that the UK economy outlook could even worsen. Steve Richards on BBC Radio 4’s Today described that even when the Coalition manage to get the ill-fated Bill this morning onto the Statute books it will almost certainly fail in its implementation. The Government had a critical role in encouraging a culture of cooperation over its reforms, and it failed over a number of fronts. It has failed to publish the Risk Registers which we now know contained information which severely undermined the Government’s case, the public do not seem in favour of the Bill (with over 66000 having signed the e-petition already), and the vast majority of the medical Royal Colleges have now declared that they have several reservations about the Bill or oppose it outright. The implementation of the Bill so far is completely apposite to what most management consultants would advise at this point; most would recommend active focus groups to seek the opinions of those who work in the NHS, particularly doctors, nurses and healthcare professionals to overcome the barriers to cultural change posed by the Bill. Instead, there seems to have been expensive active consultation from management consultancy firms and private healthcare insurance companies instead, which could further compound resentment.
The solution therefore to me is clear. There is no point this being enacted in its current form, and there needs to be a mature development of the Bill which does take into account the difference between price, cost, value and quality of different health ‘products’ such as goods and services. Not only that, it would be critical for the Presidents of the Royal Colleges of medicine, including RCP, RCGP, RCN, RCOG, and RCS to help to develop policy, and to be engaged in genuine consultations with their members about how to progress with the public. The only solution is therefore to rip up the Bill, and start again, as this is the only way to avoid resentment and a doomed implementation of the NHS strategic change. It will be far less costly in the long-term. David Cameron, through his charisma, may feel that he is able to last the course, but I actually severe doubt this. With all the best will in the world, I feel that his transformative leadership will fail as shown by the results from the change, and the Bill could even make Cameron known for toxic leadership rather than charismatic leadership. To add insult to injury, satisfaction ratings were at an all-time high, and the Lancet debunked the myth that productivity had been adversely affected under Labour too.
Currently the Coalition are trying desperately to present this as outright opposition to modernisation; this is a blatant lie, as they are denying the chief stakeholders a say in any ‘bottom-up organisation’. The implementation of this Bill is doomed to fail. I bet my life on it.
The author is President of the BPP Legal Awareness Society, and this article does not represent the views of the Society, nor of BPP.
