On it's 70th anniversary, Lucy Maber asks whether the NHS needs to redefine its purpose.
This article is part of our feature on the future of healthcare, you can check out Issue 2 of Magpie here.
The National Health Service (NHS) is no stranger to intense scrutiny and criticism. Lauded as one of the world’s greatest healthcare systems by some, decried as a catastrophic failure by others, it has occupied a central position in British political life since its foundation, with countless commentaries and solutions put forward to try and change it, improve it, ‘fix’ it.
And while not wanting to add to the in-tray of Simon Stevens, chief executive of NHS England 1, it is possible to go beyond this sterile debate, and begin to reframe how we think about the NHS. By using the tools of purpose and employee engagement, we can move away from scratching the surface of operational solutions. The suggestion here is that the NHS needs an emotional heart transplant – and then that greater change, on an operational level, will cascade from there.
Take purpose first: the NHS was founded 70 years ago with a clear mission to provide healthcare to everyone regardless of location or income. But is this still even possible in light of the demands and expectations of patients today?
And secondly, engagement: it is fair to say that everyone who works in the NHS is compelled on a personal level by their own innate sense of purpose yet
disenfranchised with the very system that ought to be bringing it to life. How do you begin to engage a workforce stuck in a totally unique bind?
The essence of being British
The NHS was born on 5th July 1948, and for the first time hospitals, doctors, nurses, pharmacists, opticians and dentists were brought under one organisational umbrella to provide services that were free for all at the point of delivery. It was revolutionary – a system financed entirely through taxation so that people could access healthcare without financial worry.
Since its inception the service has been guided by the same three principles: to meet the needs of everyone; to be free at the point of delivery; and to be based on clinical need, not the ability to pay.
The NHS fundamentally changed the UK’s healthcare infrastructure. But in a far deeper, visceral way, what the NHS stands for has become something that people are fiercely proud and protective of. In 2014 a survey asked the British public, “What is the essence of being British?” The most common response – having access to the NHS.
This strength of sentiment makes it impossible to tackle the problems the NHS faces with merely functional, organisational or structural changes. Anything that
threatens the integrity of providing universal healthcare goes against the very grain of what it is to be British.
But the UK has changed beyond recognition since the early days of the NHS. A population that is both aging rapidly and more ethnically diverse, is now posing very real problems in providing healthcare. Combined with rapid technological development, and its accompanying expectations, and you can see why the NHS is not just a perennial political hot potato, but also struggling to fulfil its purpose.
And whereas most organisations would have adapted, the NHS has stuck to its founding principles. That in itself isn’t a bad thing – but it poses an interesting challenge.If we looked at the NHS’ purpose as we might do for a private company, what might we learn? In short, does the purpose of the NHS need to be redefined?
"In a far deeper, visceral way, what the NHS stands for has become something that people are fiercely proud of and protective of."
Limitless, without direction
A good business purpose is a north star – it frames a sense of direction; guides decision making; gives a framework for reporting and measuring success, and helps an organisation navigate transformation. Take Unilever as an example. Its purpose states that to succeed requires “the highest standards of corporate behaviour towards everyone we work with, the communities we touch, and the environment on which we have an impact.”
This is a clear example of a purpose that:
- Qualifies what success looks like. Although it is still broad, it is quantifiable and can easily be supported by targets or proof points. That flexibility is important to capture so that the purpose can be relevant for all parts of what is a huge, complex, diverse, global business
- Has boundaries. The people that they work with, the communities that they touch and the environment. It does not pertain to every person in every circumstance. Although broad, it has a sense of being finite and quantifiable.
Now think about the NHS. It was created to be, effectively, a ‘boundary-less’ institution – its very nature is to be indiscriminate in who it provides for. A private business knows who it serves – there’s a clear line in the sand. But the NHS is meant to be limitless by its very nature, conception and heritage.
Which then poses a real problem as to how it can gain any sense of direction. If the purpose of the institution effectively limitless, how can anyone derive a realistic set of guiding principles for decision making or how to invest resources?
We know that patients are invested in the NHS – both emotionally and as taxpayers. As an institution, it is directly accountable to us; we are the ‘shareholders’. But this doesn’t necessarily take into account that our expectations around what should be available and invested in are defined around what we, as individuals, need. And of course, my needs as a health-conscious 27-year-old living in Central London will be different from an octogenarian living in the North East – and yet we will both expect that the NHS will serve us both, comprehensively.
"A good business purpose is a north star - it guides decision making and helps and organisation navigate transformation."
Purpose as a foundation
But if you look closely amongst the complexity that is NHS England, you can start to see organisations experimenting with and using purpose as a tool.
Take the Royal Marsden as an example. A NHS Foundation Trust2, it’s one of the world’s leading hospital dedicated to cancer diagnosis, treatment, research and education. It’s a specialist institution with a separately defined purpose: to “continue to make a national and global contribution to cancer research and treatment, so that more people are cured and quality of life is improved for those living with cancer.”
Though NHS foundation trusts operate under the NHS umbrella and are governed by the same principles (free care based on need, not ability to pay), they are not subject to centralised direction. Rather they are run at a local level and are accountable to local patients and communities. This instantly lessens their scope of responsibility. Some parameters have been drawn and suddenly their purpose is ring-fenced.
In the example of the Royal Marsden, focusing only on cancer patients is, arguably, critical to its success. The organisation knows who to serve and who not. Patient expectations are managed. A sense of purpose is clear. Its reputation for excellence is not solely down to having this, of course, but certainly goes a long way to establishing it.
Motivating the motivated
Of course, excellence cannot be delivered without a workforce. Medicine is an industry where those who choose to work in it are often motivated by something higher – the individual pursuit of a greater purpose.
And yet the NHS’ workforce is disenchanted with the system. Last year there were 17,707 registered complaints regarding the values and behaviour of the staff, whilst in 2015 the number of staff who experienced harassment, bullying or abuse from patients, relatives or the public was staggering (47% of ambulance workers, for example).
So on the one hand individual employees are likely motivated by their own sense of purpose; and the ideology behind the NHS chimes with that. But at the same time it’s a difficult place to work and these people are on the frontline when it comes to abuse and dealing with the strain on the system.
The question then is whether the organisation’s purpose is enough to transcend an individual staff member’s experience? Or is the system too reliant on the individual’s sense of purpose to stop them from moving to the private sector, or even leaving healthcare altogether?
There are countless case studies that show how an engaged workforce can turn a business’ success around. Engaged employees are motivated to do their best work, productivity shoots up and you retain the best talent. People want to come to work, they understand their job and critically, they know how their work contributes to the overall success of the organisation.
One of the most compelling ways to engage a disenfranchised workforce is to bring them back into a central narrative that’s founded on real-life success stories. Take Diageo as an example, an organisation with a strong if recessive masterbrand, and dominant product brands.
For International Women’s Day, it presented on its website stories from employees across their corporate business and its products. Stories not separated by function or business but instead brought together to tell a coherent and compelling story about Diageo. And it really should be possible to start doing something similar for the NHS. These staff stories and successes exist – they’ve just not been joined together, across the system’s disparate entities.
Re-engaging a disenfranchised workforce is a complex and long process and storytelling is by no means a quick-fix to improve staff morale. Yet telling the compelling stories from throughout the organisation is a simple and effective starting point. Celebrating successes, homing in on the stories that support a clear purpose and owning areas of excellence could do wonders in establishing pride and morale amongst employees and goodwill with us, the patients.
Changing the course of the NHS is like trying to make an oil tanker do a u-turn. You can make as many functional decisions as you want, but ultimately you need to decide where you want to go and start steering.
Navigating towards a successful NHS is not easy. But should Simon Stevens come to us for some advice, our top-level thoughts would be:
- Redefine the NHS’ purpose. And try, where possible, to define boundaries.
- Re-engage your workforce. They might already have their own sense of purpose that brings them into work every day – but try to bring them on the journey to championing yours too.
1 …rather than all of the UK; thanks to devolution, NHS services in Scotland, Wales and Northern Ireland are organised and provided separately by the relevant devolved governments.
2 For simplicity’s sake, NHS trusts are the main organisations through which specific healthcare services are delivered at a local level. The UK government has an aim of making all trusts attain ‘foundation’ status in due course.