Lessons from the London Darzi fellowship

The prestigious Darzi Fellowship has now passed its 10th birthday. During that time many Darzi Fellows have experienced a unique combination of learning, development, innovation and leadership. There is an ever growing alumni of Darzi Fellows, these Fellows are a new generation of healthcare professionals, who have a clinical role or background coupled with the skills of systems leadership, and innovation.

The Darzi Fellowship is a case study in best practice for clinical leadership development. The evaluation of the London Darzi Fellowship programme carried out by Stoll et al., (2010) describes the value of the fundamental relationship between workplace and programme learning, described in the following diagram:

Eval Darzi

The report by Stoll and colleagues attributes the success of the programme (which at this stage was for doctors only) to:

  • Committed and learning oriented MD
  • Supportive Trust culture
  • Working on ‘ambitious but appropriate’ live projects
  • High quality mentoring
  • Learning programme that targets transformational change
  • Combining workplace and external learning
  • Network of support – from formal to informal social learning

As the Fellowship developed into a clinical leadership programme, and the context in which the Fellowship operated change, the design of the fellowship was iterated, and the impact remained. Conn et al., (2015) in their survey of Darzi Fellows found 94% of their 90% survey return rate reported the programme as worthwhile. 85% felt more empowered to improve health care systems, particularly through developing collaborative clinical networks.

Overall a Longtitudinal study of the Darzi fellowship (Mervyn & Malby 2017) demonstrates its effectiveness in securing clinical leadership who can contribute too and lead the Triple Aim – ensuring high quality healthcare, securing overall community health and managing costs. The study showed that:

  • Fellows are emerging as leaders, acting as catalysts for sustainable change in the healthcare environment
  • The Darzi programme continues to be successful with learning and behavioural change sustained after the Fellowship year

Malby et al (2018) found that in a review of the Darzi Fellowship “Several concurrent processes must happen for clinical LD programmes to be genuinely impactful. Leadership students must collaborate as a group or team. Innovation, the basis of systems change, is the result of a team effort. These clinical teams should be diverse, especially multidisciplinary with a level of healthy conflict, and the students must be reflective and resilient. “

The Darzi Fellowship Programme at LSBU is designed based on the principles proposed by Edmonstone (above) along with those of Swanwick and McKimm (2014) who summarize a set of principles for design of leadership development namely that they should be:

  • Practical: through the incorporation of the development of key skills such as coaching, change management, and negotiation
  • Work oriented: by including project work as a key component supported by action learning sets
  • Supportive of individual development: through 360° feedback, coaching, and mentoring
  • Link theory to practice: through the provision of selected leadership and management literature, relevant to the educational context
  • Build networks: through action learning, coaching, and social networking.

The Current Fellowship

The Darzi Fellowship supports early career clinical leaders, who take a year out from clinical training/ practice to develop their skills and capabilities in leading complex change. Fellows work on an intractable complex problem (the Fellowship Challenge) within an NHS organisation, where previous attempts to make an improvement haven’t made the difference expected; or an emerging complex problem where it’s not clear what to do. Host organisations provide an innovation space for the Fellows to test out new approaches to complex (wicked) local issues, in order to make a real difference to the quality of local health services.

The Fellowship work includes:

  • Inquiry
  • Developing a culture of change
  • Discrete projects across a system
  • Building collaborative relationships
  • Connecting theory to practice, and a better use of data in the system
  • Systems leadership

The PGCertLeadership in Health (Darzi)  takes Fellows through a journey of foundations of change, learning all the approaches needed to undertake a complex change, from scoping through to implementation and evaluation. Development of understanding of methodologies for change, personal strategies and skills for leadership including working with peers and with diversity are embedded in the programme workshops. These are applied and reviewed in Action Learning Sets and through the coaching and co-consulting sessions with Faculty where Fellows seek advice and support for the design and implementation of their change work.

A major strand throughout the programme is developing the ability to work effectively and productively with peers from diverse backgrounds (including service users). Throughout the programme the Fellows are exposed not only to the theory of clinical leadership but also to experienced clinical leaders, who share their personal approach. This also provides a network for the Fellows for current and future mentoring.

A  critical part of the Fellowship is learning about how to coproduce change with citizens as peers – here are colleagues from the LSBU Peoples Academy who join the programme.


The programme is congruent with the principles for effective leadership development identified in the last blog and re-listed here below:

Effective Leadership Development Principles and Practices

Overall the evidence suggests that any Clinical Leadership Programme needs to include the following:

  1. Adult learning methods in understanding distributed leadership, systems and how they work, power, approaches to quality, change management, collaborative decision-making. This means an inclusive, collaborative approach to learning events (workshops) with little didactic learning.
  2. Skills development in working with diversity and conflict, negotiation, personal resilience, change practices for wicked and tame problems, inquiry, critical analysis, reflection, learning to live with uncertainty, and working with people and communities as assets.
  3. Organisational application – a real piece of leadership change work where the clinical leader can practice their new knowledge and skills, and learn through doing and reflection, and peer review with colleagues in an action-learning approach.
  4. Clear mentorship of the clinical leader in their own organisation as they learn to apply their new learning in practice, providing air cover for the clinical leader to experiment with new skills and practices.
  5. Leading as peers – using the clinical leadership learning group as the case material for understanding how to work as clinical peers in a distributed leadership model.
  6. Personal Leadership application – knowledge development supported in its application by coaching.
  7. System mentorship to support ongoing careers and sustainability of the programme learning.
  8. Opportunities to build networks for personal development and support beyond the programme, and in support of the organizational change effort they are leading.

The Darzi Fellowship will shortly open for applications at LSBU for September 2019. Please contact me if you would like to host a Fellow.


Conn, R., Bali, A. & Akers, E. (2015) Taking time out of training to shed light on “the dark side’ BMJ 351:h5231

Malby, R., Mervyn, K., Boyle, T (2018) Darzi Clinical Leadership Fellows: an activity theory perspective. Journal of Health Organization and Management. Vol. 32 Issue: 6, pp.793-808

Mervyn K, and Malby, B (2018) Longitudinal Study of the Impact of the London Darzi Fellowship Programmes. Years 1 – 8. London South Bank University.

Stoll L, Foster-TurnerJ, Glenn M. (2010). Mind Shift. An evaluation of the London Darzi Fellowships in Clinical Leadership. London Deanery and IOE London

Swanwick T, McKimm J. (2014) Faculty development for leadership and management. In: Steinert Y, editor. Faculty Development for the Health Professions. New York, NY: Springer.



Does Clinical Leadership Make a Difference and how do you Develop Clinical Leaders?

ROO_0213I’m being asked about what makes effective leadership development, so here is a summary of what works! The next blog is a case study of the London Darzi Fellowship as an example.

The Impact of Clinical Leadership

Basically where there is good clinical leadership organisational performance is good – people get a better deal.

The importance of clinical leadership for healthcare change has been well described (Swanwick and McKimm, 2011, Edmonstone, 2009, Wilson et al., 2013, Malby et al., 2013). The direction of travel is clear, and to an extent this has been an ideological movement (healthcare quality will be improved and costs reduced if clinicians are at the heart of decision-making). However there is emerging evidence of the beneficial impact of clinical leadership. Kirpatrick et al (2007) conducted a National Inquiry into the relationship between management and medicine. This identified that Clinical-management engagement is often associated with a) improved productivity (through the redesign of clinical work) – Degeling et al (2003); b) enhanced capacity for change and innovation (Fitzgerald and Ferlie 2006). A number of studies have found that poor performance and clinical failure were linked in part to a ‘disconnect’ between medicine and management (Healthcare Commission 2006, Mannion et al 2005). Many have also identified a positive link between effective clinical leadership and improved patient care. There is then some evidence to suggest that improving the capacity of doctors and managers to co-produce services will add value in the system.” (p 5)

A subsequent review conducted by the Faculty of Medical Leadership and Management, The King’s Fund and the Center for Creative Leadership (West et al 2015) showed the importance of leadership in the health service. The review concluded that ‘There is clear evidence of the link between leadership and a range of important outcomes within health services, including patient satisfaction, patient mortality, organisational financial performance, staff well-being, engagement, turnover and absenteeism, and overall quality of care

Veronisi et al (2013) found a significant and positive association between a higher percentage of clinicians on boards and the quality ratings of service providers, especially where doctors are concerned ‘This positive influence is also confirmed in relation to lower morbidity rates and tests to exclude the possibility of reverse causality (doctors joining boards of already successful organisations).

Overall it is now clear that high organisational performance results when good clinical engagement occurs, and higher quality care results from strong clinical leadership (Dellve et al., 2018; Reinstern et al 2008, NICS 2003).

Clinical Leadership Development

Having recognised the need for and benefits of clinical leadership, the next issue has been the readiness of the clinical professions to take on these roles. Whilst the attitude to leadership has changed, and whilst clinicians are taking up roles that embrace leadership, their development for these roles is less robust.

Leadership development and management development has long been embedded in nursing career development, and is increasingly common in medical careers (with intercalated degrees that include management). However many hospitals have little or no management or leadership development for their consultants, or directorate leads, and that is mirrored in primary care where opportunities for GPs to develop these skills has been sparse. The readiness of medicine mirrors the early ambivalence, and sometimes vociferous opposition of the profession to integrating management into its practice. As attitudes changes the development of the profession in terms of management and leadership skills has fallen behind. This is partly because the profession has taken time to realise that management and leadership isn’t straightforward ‘common sense’. Many stories of the early days of CCGs are told where GPs believed that running their own small business was adequate preparation for committing public resources through commissioning.

No matter what the causalities the reality remains that:

…consultants rarely receive leadership training and might experience problems with the transition into management roles, particularly in relation to conflicts with their other responsibilities to patients, colleagues and life outside work.’ Lewis 2013

Successful reshaping of local health systems depends heavily on the leadership of clinicians, working with partners in social care. But clinicians are rarely trained in the major change management skills they need for the task. Moreover, they get little career support for challenging perceived boundaries between clinical and management roles. Consequently the systems leadership roles where clinicians can make such a big difference may not appear to them as attractive or feasible career opportunities.’ NHS 2016

In fact according to Edmonstone (2009) “no systematic and structured national leadership development provision for doctors existed prior to 2001-2002” (p 210).

The Darzi Fellowship programme (resulting from the 2008 Darzi review) originally for doctors and now for all the clinical professions, in its 10th year is the longest standing programme for developing clinical leaders in London. It demonstrates the value of investing in clinical leadership development (Malby and Mervyn 2017).

Leadership in high performing health systems is distributed (Denis et al 2011) and therefore in focusing on clinical leadership development for the future, the model of development should not just be for senior leaders but for the full range of clinical leaders, working at multiple levels and in multidisciplinary teams contributing to securing quality healthcare for all. This is supported by West et al (2015) report on leadership in the NHS which states that successful organisations are “leader-ful” not just “well led”.

In addressing clinical leadership effectiveness organisations need to provide clinical leadership in an integrated multidisciplinary model across all levels of organisational decision-making.

Effective Clinical Leadership Development Programmes

Of course effective clinical leadership development has many of the characteristics of any effective leadership development programme. The difference is the context in which clinical professionals join a leadership programme (the dominant role of expertise in the profession; the lack of prior leadership and management development in training).

At its heart any clinical leadership development programme needs to be based on the best intelligence about adult learning. This is the bedrock.


Adult Learning

Adult learners require far more than just information; they require a myriad of teaching technologies. These adult learning principles to the design of our programme (Knowles 1984):

  • Adults need to know why they are learning something
  • Adults learn through doing
  • Adults are problem-solvers
  • Adults learn best when the subject is of immediate use

Effective adult learning programs use double loop learning methodology based on for example Kolb’s experiential learning framework (Kolb 1984), and support continued learning and development through learning communities such as action learning sets so that participants ‘learn how to learn’, and have a deeper sets of alternative ideas and behaviours from which to choose to act (Schon 1987).

Effective Leadership Development

West et al. (2015, p 3) found that across levels of leadership development programmes – individual, task-based, team, organisational, national “…there is little robust evidence for the effectiveness of specific leadership development programmes”. However there are reappearing themes such as self-awareness and personal reflection, communication, teamwork, leadership styles, a support network, duration of one year and experiential learning, in studies of the learning impact of Leadership Development (LD) programmes. (Strawn et al., 2017; Tsyganenko, 2014, Pradarelli et al., 2016,).

In a review of Leadership development programmes Edmonstone (2013 p 537) proposed the following common design principles for effective leadership development programmes:

  • “Starting with ‘what is’
  • Focusing on the end-point
  • Real time, real work, real people
  • Explicitness about underlying values
  • Addressing system-wide issues
  • Embedding development with core business
  • Embracing diversity
  • Addressing sustainability

Effective Leadership Development Principles and Practices

Overall the evidence suggests that any Clinical Leadership Programme needs to include the following:

  1. Adult learning methods in understanding distributed leadership, systems and how they work, power, approaches to quality, change management, collaborative decision-making. This means an inclusive, collaborative approach to learning events (workshops) with little didactic learning.
  2. Skills development in working with diversity and conflict, negotiation, personal resilience, change practices for wicked and tame problems, inquiry, critical analysis, reflection, learning to live with uncertainty, and working with people and communities as assets.
  3. Organisational application – a real piece of leadership change work where the clinical leader can practice their new knowledge and skills, and learn through doing and reflection, and peer review with colleagues in an action-learning approach.
  4. Clear mentorship of the clinical leader in their own organisation as they learn to apply their new learning in practice, providing air cover for the clinical leader to experiment with new skills and practices.
  5. Leading as peers – using the clinical leadership learning group as the case material for understanding how to work as clinical peers in a distributed leadership model.
  6. Personal Leadership application – knowledge development supported in its application by coaching.
  7. System mentorship to support ongoing careers and sustainability of the programme learning.
  8. Opportunities to build networks for personal development and support beyond the programme, and in support of the organizational change effort they are leading.


Baker GR, Denis J-L. (2011) Medical leadership in health care systems: from professional authority to organizational leadership. Public Money and Management. 31:355–362.

Berwick DM, Nolan TW, Whittington J. (2008). The Triple Aim: Care, health, and cost. Health Affairs. 2008 May/June;27(3):759-769

Conn, R., Bali, A. & Akers, E. (2015) Taking time out of training to shed light on “the dark side Available at: http://careers.bmj.com/careers/advice/Taking_time_out_of_training_to_shed_light_on_%E2%80%9Cthe_dark_side%E2%80%9D# (Accessed:10/01/18)

Darzi, A. (2008). NHS Next Stage Review Leading Local Change. London: Department of Health

Darzi, A., Quilter-Pinner, H., Kibasi, T. (2018) Better health and care for all: A 10-point plan for the 2020s. The final report of the Lord Darzi Review of Health and Care. Institute for Public Policy Research. June

Degeling, P., Maxwell, S., Kennedy,J., Coyle, B. (2003)  Medicine, management, and modernisation: a “danse macabre”? British Medical Journal, 2326(7390): p. 649-652.

Dellve, L., Strömgren, M., Williamsson, A., Holden, R.J. and Eriksson, A., (2018), ‘Health care clinicians’ engagement in organizational redesign of care processes: The importance of work and organizational conditions’, Applied Ergonomics68, pp.249-257.

Denis, J.-L., & van Gestel, N. (2016). Medical doctors in healthcare leadership: theoretical and practical challenges. BMC Health Services Research16(Suppl 2), 158. http://doi.org/10.1186/s12913-016-1392-8

Edmonstone, J. (2009) Evaluating clinical leadership: a case study. Leadership in Health Services, Vol.22 Issue: 3, pp.210-224,

Edmonstone, J (2013) What is Wrong with NHS Leadership Development British Journal of Healthcare Management Vol 19 No 11 p531-538

Evans, E.J (2004). Thatcher and Thatcherism (the making of the contemporary world). 2nd Edition. Routledge

Fitzgerald, L., Lilley, C., and Ferlie, E., Addicott, R., McGivern, G., Buchana,D. (2006) Managing Change and Role Enactment in the Professionalised Organisation. National Co-ordinating Centre for NHS Service Delivery and Organisation R & D. London.

Healthcare Commission (2006) Annual Health Check. London.

Kings Fund (2011) The Future of Leadership and Management in the NHS. No more heroes. Report from The King’s Fund Commission on Leadership and Management in the NHS p ix

Kirkpatrick, I., Malby, R., Dent, M., Neogy, I., Mascie-Taylor, H., Pollard, L., (2007), National Inquiry into Management and Medicine: Final Report, Centre for Innovation in Health Management, University of Leeds, January

Lewis, M. (2013) Reflections on a changing role in clinical management. International Journal of Clinical Leadership 17 (4): 227-234

Malby, R., Mervyn, K. and Pirisi, L. (2013), ’How professionals can lead networks in the NHS’, International Journal of Leadership in Public Services, 9(1/2) pp. 4-4.

Malby, R., Mervyn, K., Boyle, T (2018) Darzi Clinical Leadership Fellows: an activity theory perspective. Journal of Health organization and Management. https://doi.org/10.1108/JHOM-05-2018-0133

Mannion, R., H.T.O. Davies, and M.N. Marshall, (2005) Cultural characteristics of “high” and “low” performing hospitals. Journal of Health Organization and Management, 19(6): p. 431.

Mervyn K, and Malby, B (2018) Longitudinal Study of the Impact of the London Darzi Fellowship Programmes. Years 1 – 8. London South Bank University.

McNulty T, Ferlie E. (2002) Reengineering Health Care: The Complexities of Organizational Transformation. Oxford: Oxford University Press

L.J. Millward., Bryan, K. (2005),Clinical leadership in health care: a position statement, Leadership in Health Services, Vol. 18 Iss 2 pp. 13 – 25

NHS (2016) Developing People – Improving Care A national framework for action on improvement and leadership development in NHS-funded services. National Imporvement and Leadership Development Board.

National Institute of Clinical Studies (NICS) (2003) Factors Supporting High Performance in Healthcare Organisations. Melbourne, Australia: NICS

Noordegraaf M. (2011) Risky business: how professionals and professional fields (must) deal with organizational issues. Organizational Studies.  32:1349–1371. doi: 10.1177/0170840611416748

Pradarelli, J.C., Jaffe, G.A., Lemak. C.H., Mulholland, M.W. (2016), A leadership development program for surgeons: First-year participant evaluation, Surgery, 160(2) pp. 256-263

Rienstern J, Bisognano M, Pugh M. (2008) Seven Leadership Leverage Points for Organizational-Level Improvement in Health Care. 2nd ed. Cambridge, MS: Institute for Healthcare Improvement;

Schön, D. (1983). The Reflective Practitioner: How professionals think in action. London: Temple Smith

Spurgeon P, Clark J, Ham C. (2011) Medical Leadership: From the Dark side to centre stage. Oxford: Radcliffe Press

Strawn, K., McKim. A.J. & Velez, J.J. (2017), Linking Experiences and Outcomes within a Postsecondary Leadership Development Program. Journal of Leadership Education, 16(1) pp. 34-46

Storey, J. and Holti, R. (2013) Possibilities and pitfalls for clinical leadership in improving service quality, innovation and productivity. National institute for health research service delivery and Organisation Programme

Swanick, T., McKimm, J. (2011) What is Clinical Leadership…and why is it important. The Clinical Teacher. Blackwell Publishing. Vol 8 P22-26.

Swanwick T, McKimm J. Faculty development for leadership and management. In: Steinert Y, editor. Faculty Development for the Health Professions. New York, NY: Springer; 2014.

Tsyganenko, M.V. (2014), The Effect of a Leadership Development Program on Behavioral and Financial Outcomes: Kazakhstani Experience, Procedia Social and Behavioral Sciences, 124 pp. 486-495

Veronesi, G., Kirkpatrick, I. and Vallascas, F. (2013) Clinicians on the board: What difference does it make?, Social Science & Medicine, 77, pp. 147–155.

West, M., Armit, K., Loewenthal, L., Eckert, R., West, T., Leed, A. (2015): Leadership and leadership development in health care. The Evidence Base. Faculty of Medical Leadership and Management, The King’s Fund and the Center for Creative Leadership. Kings Fund

Wilson, L., Orff, S., Gerry, T., Shirley, B. R., Tabor, D., Caiazzo, K. and Rouleau, D. (2013), Evolution of an innovative role: the clinical nurse leader, Journal of Nursing Management, 21(1) pp. 175-181.

Primary Care & Scale. Who should we be collaborating with?

Screen Shot 2018-06-15 at 16.42.13Seduced by Structure

As we wait for the next round of policy papers on the size and shape of GP practice organisations and primary care teams, I’m struck by how much structure always becomes the answer. Many reshaping documents start with the structures of the institutions rather than the identity and capacity of communities, and yet General Practice has grown out of communities, and practices are deeply embedded in their local place.

I thought it would be useful to offer a view about scale from the place of relationships and needs, rather than institutions and structure. But first of all the practices need to be ready to collaborate.

The Fantasy of the Future

The next seduction is to get into a fantasy about how fast the primary care system can move into these new collaborations. The starting place for the policy is well functioning practices with increasingly complex work, whereas many practices aren’t at the starting blocks yet.

Any development of ‘at scale’ collaboration needs the bedrock of efficient practices working with resilient communities.

We know that practices that are adapting effectively to the context of increase complexity [London Primary Care Quality Academy]:

  • Use data to understand presenting needs, review activity and improve the flow through the practice system. Understand their demand and ways of meeting that demand (data capture of patterns of demand and flow in the practice; how they offer appointments and who gets turned away; understanding the profile of their frequent attenders; and their low attenders; number of DNAs.
  • Collaborate with communities to coproduce services locally
  • Use their skill sets more effectively to meet need (diversify their workforce)
  • Use their contact time with patients more effectively (triage, mixed model of appointments)
  • Improve their back office functions to work efficiently (managing the paperwork)
  • Reach out to partner with other providers to manage complex health (care homes, social care, third sector, mental and acute health).
  • Learn fast, looking for examples outside their practice to steal with pride; establishing peer review for their clinical practice across professions. They test and prototype new ideas and check the impact on their demand and capacity using data.

This is the ‘Readiness Stage’, the foundations that practices need before they start collaborating (and merging/ partnering), because this stage exposes the nature of the actual work in practices, and where best the practice teams can intervene, and therefore where they need to collaborate to provide the best option. It also requires practice members to work collaboratively together, beyond the individual roles but as peers to bring all their experience and ideas as a team.

What Scale for What Work?

There are four main resources that secure health and wellbeing in communities –the community itself, the NHS, local government and the third sector. You can’t change General Practice without consideration for the other groups.

In my view there are these ‘scales’ for primary care service development:

Screen Shot 2018-06-14 at 13.48.10

Scale 1: The Community: Up to circa 14,000

General Practices grew out of local communities. These communities have natural boundaries, characteristics, relationships and resources. They have stories they can tell about themselves as a community. They recognise people from their community as being one of them. Most communities are at a scale of up to circa 14,000. This is the size of a small town. Go beyond that and people don’t feel like they are part of something they can identify with – it becomes something others ‘own’ and belong too. They don’t feel that its something they can contribute too.

At 30-50K scale that is the current favourite scale, people don’t identify themselves as a community, there are conflicting stories and different cultures. They see people as ‘other’ and its not a size that generates any sense of belonging.

The NHS could be seen as having generated an over dependence on its services borne out of the founding principles of the NHS ‘Can do, Should do’ and medical model ideology. There are many proponents of the assets that communities can and should bring to their health, and examples emerging beyond social prescribing (language that is laden with the intent that power stays in the hands of the prescriber see Corman Russell’s blog on this),to a partnership model with communities that has the potential to reduce demand.

There are masses of assets in communities or perhaps more accessibly – people who want to volunteer and help each other. We need these people to help with the volume of ‘patients’ presenting with ‘trouble with life’. This has to be the bedrock of any further ‘at scale’ working . See my previous blog on Reducing Demand in Primary Care.

Primary care for the future needs to be built out from resilient communities. So this is the first productive scale for primary care.

Scale Two: The Locality: 30-100K

(a) Across General Practices

At 30-50K

At this scale you can generate efficiencies in the Practice Business Model:

  • Sharing back office functions
  • Sharing workforce (particularly non-GP professionals and receptions staff)
At 30-100K

At this scale collaborating practices can provide some diagnostics, and more specialised rapid assessment and treatment functions to support GP/ Primary care teams work. See the work of Eastleigh Southern Parishes Locality

Aligning with Care Homes

Care homes provide better care where they are aligned with a practice. Within a borough a practice could specialise in this service for a geographical areas akin to Localities.

(b) As part of Integrated Teams

When you have resilient communities working to support local health and wellbeing, and you have functioning general practices, alongside collaborations for business efficiencies, then the next step is how to collaborate with other service providers to manage complex conditions, to prevent people with complex needs becoming unstable.

At the moment there seems to be a focus on growing these collabortions out of primary care, rather than developing integrated MDTs that bring the best of the skills needed from all service providers locally to bear on the complex needs of specific population groups e.g.

  • People who are frail
  • Adults who have both mental and physical health needs
  • Young people with both mental and physical health needs
  • People who have trouble with life which means they can’t cope with their health issues

These different groups require different MDTs with different skills and leadership. The General Practice team are members not neccessarily the leaders. For these teams the GP and practice members are peers in the team. As yet there is some way to go before we have the level of self-organising integrated MDTs that can work collaboratively with devolved authority to support people who have complex needs, preventing them from moving from stable to unstable. The MDT will have different professions taking the lead dependent on the severity of need. So for combined mental and physical health, it could be the community nurse at the lower levels of severity, a GP at a mid level but a Psychiatrist at higher level of severity. People with complex needs do need algorithms that identify the intensity and level of expertise of support required see the Intermountain work (Reiss Brennem at al 2016 ) and Western HealthLinks, Australia.

We at LSBU London Primary Care Quality Academy have the early ideas for the model here:

Screen Shot 2018-06-14 at 14.36.48

Scale 3: The Borough : 150K – 350K

At Borough scale there seem to be two main functions:

  • Some service delivery potential across a larger population.
  • Business Intelligence and Learning : A ‘Collaborative’ where members can work together to spread and share intelligence and to learn. This is in effect a development agency for the NHS in that place. Here Primary Care teams are supported by an Research and Development Team. Every industry needs its R&D function to innovate and adapt. Borough level organisations (e.g. Federations) can partner with AHSNs and CCGs to secure the best business intelligence (data) for quality, and to secure organisational development programmes for member teams, and clinical / professional leadership programmes for leaders.

All of these scales require different relationships:

Screen Shot 2018-06-15 at 15.43.32

And therefore different organisational forms:

Screen Shot 2018-06-15 at 16.06.44

And therefore different personal development capabilities:

  • At the Community and Practice level teams need good management development, team working and coproduction.
  • At the partnership level people leading these need good leadership skills for effective organisational collaboration.
  • At the locality scale people need peer leadership capabilities.
  • For the Borough scale people leading these need good Network Leadership skills.

As you can see a one-size-fits all approach might suit the NHS, but what’s needed is Collaborations borne from an understanding of need, and development to support the nature of that collaboration.

Do get in touch if you are interested in this work.


Frequent Attenders – Breaking the Cycle in Primary Care

People who attend GP practices on a very regular basis are usually seen as one and the same ‘type’ – elderly, multiple conditions (co-morbidities), often including a mental health issue. Despite the person booking multiple 10 minute appointments (sometimes a week), often all they are offered are more 10 minute appointments. Clearly this isn’t working, so what does?

It will be no surprise that there isn’t a magic bullet, but there are a range of approaches that can help, could work and do work.

The first step is to know who these people are, at a level of detail that helps you classify them beyond the number of times they attend (though that’s a good starting point). Morriss et al (2012) found the top 3% of attenders are associated with 15% of all appointments, alongside increased in hospital visits and mental health indicators.

Start with data

So who are people that turn up all the time? Whilst you will have some ideas (and prejudices) sometimes it turns out its not who you think it is. Here is an example from one practice in our London Primary Care Quality Academy, where we found that the top 5% of patients may be using 20% of GP resources at the practice.

The practice may not be thinking in a joined-up way about how it is spending this resource.

Screen Shot 2018-06-05 at 18.23.23

Not only is the practice not meeting these people’s needs, they are spending a lot of money in the process, you can see in the next diagram how this practice is spending 1.5-3K on its Super Attenders, and if you take the people who attend every 3 weeks or more, over 5 years this practice has spent £1million on a service that’s not working.

Screen Shot 2018-06-05 at 18.24.31

Now if you look at who these people are in this practice we had a surprise, as you can see its not all mental health, or old people – it’s a range of people with a range of conditions – so what’s going on?

Screen Shot 2018-06-05 at 18.25.14

The next step is to conduct a deep dive into a range of these people individually. In this case it looks like the problem is ‘trouble with life’ i.e. these people have conditions that other people are coping with, but their context is much more messy and complex and they just can’t cope. Here is a first review of the top 100 in one practice.

Screen Shot 2018-06-06 at 11.36.33Screen Shot 2018-06-06 at 11.38.18

These deep dives are Patient History Maps which are deliberately created manually. By having a summary history map, we can begin to look for insights into how services have interacted with the patient. Where there have been handoffs, where there has been failure demand, where education and other services have been effective. We seek to understand why services and systems act as they do, and the thinking behind it. In summary we seek to understand context and how perhaps sometimes services treat presentations, but not slow the decline in health. They complement the quantitative data captured above. These maps present professionals and senior management with the vital opportunity to do their own enquiry – creating a normative learning loop (Downham 2018).

It is likely in your frequent attender group that you have a range of people, which we have categorised differently as they need different responses:

  1. People with multiple needs
  2. People with increasingly complex physical needs
  3. People with increasingly complex mental and physical needs
  4. People with extremely complex situations which means they can’t cope with their physical/ mental condition.

You can also take a needs based approach to discover the people who are likely to become super attenders – the ones in the low end of the frequency spectrum who have chronic conditions that are relatively stable, but are at risk of becoming unstable (the frailty index for older people would be a good starting point).

Determine the type of need

Clearly going round and round the system isn’t working, and we know that often multiple attendances in general practice also equates to multiple attendance in A&E, which in turn equates to the burden of multimorbidity which is independently associated with social deprivation (Hull, 2018).

The next step is to work through the list and choose from a range of interventions for this cohort of primary care users as follows:

  • People with multiple conditions, which are chronic but stable.

These people (often older in terms of prevalence, but they can be any age) with multiple conditions where a 10 minute appointment only addresses one of their multiple concerns. Here the evidence is that continuity of clinician and longer less frequent appointments scheduled regularly and self-bookable by the person is the best solution[1] (Deeny et al 2017). In terms of best practice, it is considered to be an initial consultation of circa 1 hour[2], and from then on the clinician and person decide how much time the follow-up appointments need, reducing over time as able. Overall this signals that the practice is offering a more tailored consultation approach to meet needs (see log on Reducing Demand in Primary Care part 1 and 2), and so this does need to be part of the change in how the GP system works with triage, e-consult, diversifying the workforce, and offering walk-in and bookable appointments, as this generates the headroom and appointment space to be able to offer the longer appointments.

  • People with mental and physical health problems.

Here the Intermountain approach could work, where the introduction of team based assessment and care reduced hospital admissions, (Reiss-Brennen et al 2016). This approach is to:

  1. Assess the person’s mental health severity, physical health and life situation/social factors to build a holistic picture of their health and complexity of the context they operate in.
  2. Review the assets available within the person’s own context (family / friends) and build the team needed to meet that person’s needs including the person’s own assets.
  3. Develop an integrated team response for this person.
  • People who lack confidence, are undervalued, lack meaning.

These people need to use their skills and make a contribution to feel valued. All the work on coproduction shows that people who are seen to be the most ‘needy’ by the institution, have amazing capabilities to offer, and if used it brings phenomenal self-efficacy (e.g. Coproducing Leeds). Taking a partnership approach with communities to develop new ways of bringing people together (an asset based community type approach), where the practice invites people to work with them to support the health and wellbeing of communities, and co-develops and co-provides a number of activities that regain people’s creativity and fun, and tackles the social determinants of poor health. Healthier Fleetwood is a great example of this, as is the Health Champions approach of Altogether Better. Although as Husk 2017 whilst all good sense tells us that these approaches work, the evidence lags behind practice, and there is no specific evidence for people who attend frequently. We are finding that (and its early days with a very few people so not reliable yet) where the people who are attending regularly become an asset bringing their talents and gifts to the practice and community, their need for appointments reduces.

  • People with complex needs tipping into instability, but who are currently stable.

Here you need to convene the MDT, which will need clear agreements about integrated decision-making and a devolved budget. The job here is to prevent escalation.

Look after your infrequent attenders

All of these expensive 10 minute appointments are of course being paid for from a list that includes people that don’t attend at all or very much. Without them the practice can’t afford to provide services for those that need it. The per-head budget relies on the practice having a mixed list. So what happens when one of your infrequent attenders needs an appointment and there is a wait, or they don’t get through on the phone? Well they could take their business elsewhere. We encourage practices to look after their low attenders, partly to keep them as customers, and partly because prevention starts with these people. Most teenagers and young people don’t have any contact with primary care. Treating complex health needs starts with helping people to reduce their likelihood of developing them in the first place.

You can find out more about the London Primary Care Quality Academy here

Related Blogs Primary Care Reducing Demand Part one  and Part Two

And a good read here from The Health Foundation


Deeny, S., Gardner, T., Al-Zaidy, S., Barker, I., Steventon, A. (2017) Briefing: Reducing Hospital Admission by Improving Continuity of Care in General Practice. The Health Foundation, London.

Downham, N. (2018) Case History Mapping. London South Bank University.

Hull, S., Homer, K., Boomla, K., Robson, J., Ashworth, M. (2018). Population and patient factors affecting emergency department attendance in London: Retrospective cohort analysis of linked primary and secondary care records. British Journal of General Practice, 68.

Husk, K.(2017) Social prescribing offers huge potential but requires a nuanced evidence base. The BMJ Opinion. July 18 https://blogs.bmj.com/bmj/2017/07/18/social-prescribing-offers-huge-potential-but-requires-a-nuanced-evidence-base/

Morriss,R., Kai, J., Atha, C., Avery, A., Bayes, S., Franklin, M., George, T., James, M., Malins, S., McDonald, R., Patel, S., Stubley, M., Yang, M. (2012) BMC Family Practice 13:39.

Reiss Brennen, B., Brunisholz, K,D., Dredge, C., Briot, P.,Grazier, K., Wilcox, A., Savitz, L., James, B. (2016) Association of integrated team-based care with health care quality, utilization, and cost, JAMA, 316(8):826-834.

[1] People aged 62-82 had 6% fewer hospital admissions where they saw the same GP more consistently (same GP 2 more times out of every 10).

[2] This is primarily tacit knowledge

Functioning Federations

blur-blurry-close-up-167259alex-club_3014712b (photo credit)

Primary Care Federations are now accepted as the new form of collaboration between practices. They organise in a range of relationships from alliances, partnerships, networks, to joint ventures (BMA 2018), and have a number of roles, but their primary purpose is to add value to member practices, and generate collaborative quality delivery of primary care services. They do this as member organisations.

Interestingly much of the guidance for Federations is on the structure, the legal and financial frameworks, the communications and the ideas into action (NHS England 2016); but there is very little on how Federations organise.

In my view they have two main choices in terms of how they organise the relationships  between members, that have very different implications in terms of decision-making, governance and ability to be innovative.

  1. They work as a Club – Members pay fees and they receive services. The executive team, based on intelligence from the members, decides the services. If members don’t find the services useful they can decide to leave the club. Being a member in a club comes with clear boundaries (who can join) and sanctions (how members behave). These are really membership service organisations.
  2. They work as a Network – Using a clear shared purpose as its guide (usually about better primary care for the local population), Federations as Networks work collaboratively with members to collectively generate solutions to member problems, to advocate on behalf of members, to filter intelligence (there is a lot of advise being developed for primary care) to inform members, and to commission services on behalf of members. This is a peer-based relationship in service to members, bringing the diversity of membership into creative conversations and problem solving.

Networks are innovative forms that enable members to adapt, enabling the best of their members’ assets and resources for a collective and individual member benefit (Malby and Anderson Wallace 2016). They are democratic forms which, when well lead, can secure a future focused approach to collaboration.

Clubs are more akin to hierarchies with intelligence, decision-making, and governance residing in a central team. Here delegated authority can lead to a fixed approach, costly overheads and an inability to adapt and innovate.

The Advantages and Disadvantages of the Club Approach for Federations

The advantage is that these Federations can quickly mobilise to secure funding streams.

The disadvantage is that these Federations become increasingly hierarchical as they project manage services. The services that they provide can in fact disable the local primary care system by:

  • Providing sticking plaster solutions rather than addressing the fundamental redesign that primary care needs to be fit for purpose. Often Federations have a short term view of securing enough access and capacity. Our work through the London Primary Care Quality Academy is finding that the practices we work with are usually convinced at the outset that they cannot cope with rising demand. Using data generated by the practices we find that (a) demand isn’t always rising but the complexity of the demand is changing and (b) if they change the way they organise, particularly their ‘sorting’, they do have the capacity, and can even generate more capacity, reducing their DNAs, and offering more appointments. Practices need support to understand and manage their demand and then support to work with communities to reduce demand. However Federations in the Club mode don’t necessarily have the collective capacity to work upstream, they tend to generate a dependency culture that ‘fixes’ their member’s problems in ways that can stack up more problems in the future. This perpetuates an individual member approach rather than bringing members together to collaborate. It also means that members become passive recipients making it harder and harder for the Federation to function, as it gets nothing back from the members apart from their membership funds.
  • Becoming caught up in project management – the bureaucracy of managing the reporting and project demands of external programme funding. Often these types of organisations end up using member’s fees to subsidise the costs of the projects they have taken on with external funding. Often Federations underestimate the time and cost of administering these new programmes and services. They end up taking on more staff and then have the pressure to keep on securing funding to pay ongoing salaries. It becomes a self-perpetuating circle that looses track of members real needs.

We see more of this approach in Federations as it has a more traditional management feel to it, and is a model that is familiar to many leaders. It is in effect a hierarchy.

The Advantages and Disadvantages of the Network Approach for Federations

The biggest disadvantage is that many federation leaders are unfamiliar with what it takes to lead a network.  In networks leaders are facilitators and enablers rather than experts and fixers, and this may not be a set of skills that Federation leaders are familiar with. Networks also take time to get going, their effectiveness is predicated on building momentum amongst members not on behalf of members. It requires members to put some effort in at the outset to collectively develop their Federation. Where practices have become passive players in a system controlled by CCGs, and where change is incentivised rather than co-created, it does require a change in culture.

The advantage of a network approach is that it brings all the members into the work of the Federation, so that everyone contributes and everyone benefits. It generates accountability and brings practices closer together. It helps collaboration and generates sustainability. Everyone contributes and everyone gains. Here the members hold the network leadership team (the executive) to account , and also hold each other to account as peers. Networks are the best form for spreading innovation and knowledge. They are excellent at filtering evidence and intelligence, and in ensuring members voice is amplified. They build community and secure impact across all members. It is possible to deliver services through a network model – the advantages being that the whole membership takes responsibility and co-designs the service. In terms of contracting services on behalf of members, the network again can do this as a service function, with a membership sub-group taking responsibility, or the members delegate authority to a core team.

What this means for Federations

These very different forms (Club and Network) determine:

  • What counts as added value
  • What collaboration looks like
  • The responsibility and accountability of the Federation central team and of members.

Here is an example of the work of one Federation: Federated 4 Health

Screen Shot 2018-04-19 at 08.56.53

On the whole most Federations are doing these types of activities and I have laid out which approach (Club or Network) best suits the work, and the relative impact.

All of the work of a Federation can be done through either model, but in my view the Network model is more effective.




Spreading clinical best practice This tends to be an information giving approach with little filtering. Impact: Poor A learning approach with the network generating a sub group to filter evidence and share with members. Impact: Good
Development of quality and safety systems There is no reason for a member to take part in this unless it is a mandated part of membership.  Impact: Poor A learning approach – with self-selected members taking a lead and working with all members to secure the development of quality and safety systems across all members for the benefit of the population. Impact: Good
Consistent services Hard to secure in a passive membership without incentives.  Impact: Poor A learning and development approach to securing consistency through peer support and identification with the collective benefit. Impact: Good
Sharing and avoiding duplication of policy and paperwork Mediated through the central team. Impact: Good Can be mediated by the leadership team or delegated to a sub team. Impact: Good
Sharing of staff expertise Mediated through the central team. Impact: OK Directly between members. Impact: Good
Purchasing together (from consumables, to training, to legal advice) Managed by the central team. Can be poorly informed.  Impact: – depends on local relationships Specification agreed by whole membership as a result of collaborative service review. Managed by sub-team of leadership team. Impact: Good
Tendering Managed by the central team. Can be poorly informed. Can mean some practices are favoured over others. Impact: – depends on local relationships. Agreed by the membership with collaborative agreements about securing equal distribution. Impact: Good
Developing and using business intelligence (BI) Depends on whether there is a BI function in the central team Depends on whether there is a BI function in the leadership team or amongst members.
Premises and infrastructure Back office systems Brokered by central team. Impact: Good Emerges from collaborative relationships. Impact: Good
Education and training Commissioned by the central team based on member identified need. Impact: depends on uptake and relevance. Commissioned by the network via the administrative team, Quality Assurance from a sub-group, and learning needs are identified collaboratively. Impact: more likely to generate uptake.
Collaborative care models Brokered by central team. Impact: depends on how engaged practices are. Emerges from collaborative relationships. Impact: Good – real buy in.
Working with secondary care Brokered by central team.  Impact: depends on vision, relationships with secondary care, and ability to secure compliance from members. Network sub group working on behalf of members, bringing decisions back to members. Time spent understanding the issues and developing relationships across multiple members with secondary care. Impact: can be good where there is a collective response.
Better engagement with the local population Brokered through an engagement model. Impact: partial Coproduced with citizens as partners. Impact: mutual assets that secure new approaches to reducing demand.

In the literature on Federations the network form is often associated with smaller groups of practices (Imison et al 2018) but this fails to understand the different types of networks. Delivery networks are often larger groups of organisations, and have a delegated governance model.

Federations, to ensure they have the capacity to adapt and innovate at the front line of the NHS need to develop network leadership capabilities and design collaborative network relationships between and across members to realize the assets of the whole primary care system.

The Source 4 Networks diagnostic tools are a good starting point for securing member-wide agreement on vision, direction and participation.


BMA (2018) GP Networks and Federations. Updated February 2018. BMA Online (accessed 27 March 2018)

Imison, C., Williams, S., Smith, J., Dingwall, C. (2013) Toolkit to Support the Development of Primary Care Federations. Kings Fund, Nuffield Trust, Hempsons.

Malby, B., & Anderson-Wallace, M. (2016) Networks in Healthcare. Managing Complex Relationships. Emerald.

NHS England South (South West). (2016) Supporting Sustainable General Practice. A guide to networks and federations for general practice. (Accessed 27 March 2018)

New Models of Care – Key Ingredients of Success

Screen Shot 2018-03-05 at 11.03.42An Interview with Dame Jackie Daniel, Chief Executive of University Hospitals of Morecambe Bay NHS Foundation Trust


The Darzi Fellows from Kent Surrey and Sussex (KSS) recently interviewed people who were leading Vanguards nationally and locally, and went to visit a site. As I was listening I was struck by how difficult it was for the NHS to see the key ingredients to these models, primarily because the success is framed by the current lens of the NHS (the dominance of hierarchy), and partly because they were busy ‘getting on’.

We worked with the KSS Darzi Fellows and together generated this list of key ingredients for any new model of care:

Screen Shot 2018-03-05 at 08.29.36

I then ran these past Jackie Daniel Chief Executive of University hospitals of Morecambe Bay NHS Foundation Trust, a Vanguard that in my view has managed to do the very difficult work of truly collaborating across a whole system for better services and health. This is what she said about what it takes to collaborate to develop new solutions to intractable problems in new models of care.

Commitment to Act Together

There is no short cut to spending time together and making decisions together. The early meetings didn’t have agendas, just conversations for quite a long time. Bay Together spent a day together every fortnight talking about nothing but system work in the same building. This meant doing the business together, having meetings with clinicians on the clinical agenda, working through the money, doing big and small meetings including board meetings.

When asking acute sector teams to spend time working on primary care pathways, which were a significant investment of time, they had to hold onto the need to develop the collaboration.

She said you have to be connected but not controlled. Bay Together have appointed multiple system GP leads – ICC leads, a GP Director of Primary Care Development and a Lead for Population Health (to try and knot the threads together so that the system including the other providers can make some sense of the complexity).

They have taken time to create coalitions and networks that are agile and nimble.

Devolve to Local Teams

Originally they had 2 Federations, then they found that that didn’t work out as it wasn’t local enough. The issue isn’t structure it’s the relationships you need to do the work, so now they have 12 ICC leads as GPs.

They recognised that you mustn’t drown these teams in project management, and that solution won’t do it, you need multiple solutions. She said that they needed to have teams in discovery mode, so they definitely didn’t need to be threatened with performance management approaches. In her view they had to make the most of the diversity they had in our teams to generate the solutions.

Devolve as much of the money as you can to integrated care teams in localities. Ask these teams what configuration of spend would work better.

Work with the Public

You have to talk to the general public, and it can’t be superficial. It’s got to matter. This helps partners understand that this is commitment to a multigenerational investment strategy (an investment in health of the place).


You need your NEDs fully engaged all the way through, as you have to have agreement across all the Boards. You have to agree one budget across all the partners. The leaders need to talk about all the cultural issues and hold each other to account across a diverse group.

Don’t have contracts being delivered by organisations outside your area; you need all your contracts back into local teams.

What Generates Progress

  • Mindset – having sufficient trust to delegate decision-making, and to suspend belief on normal activity.
  • General practice needs to feel they have influence.
  • The solutions are found a many levels in terms of scale or focus (investment/ strategic priority shift/ technology). You need the right listening from top.
  • There is a level of detail at the front where they understand the consequences, and get overwhelmed by detail. You need data to help translate top to bottom and visa versa.
  • It needs real commitment to the meaning of the work.
  • Bend the rules, do whatever we can to work differently
  • Illuminate the ‘how too’.

I was struck by the relentless commitment to focus on the meaning of their endeavor, which in turn frames all their effort to work collaboratively in service to the local population. This persistent focus on purpose, on innovation locally, on relationships to enable collaboration, on data to know what’s working, on devolving decisions to where the work is done, on working with the local population as partners, on keeping the tops and frontline connected, and on holding off the temptation to project manage the life out of people are the key ingredients to success.


Rules of thumb of ‘modernised’ public services – our current rules are failing us

particpation is power

February 2018

Guest Blog by Diane Plamping with commentary by Becky Malby

NHS Rules of Thumb

We wrote an article in 1998 in which we suggested that stability in complex systems emerges from the rules that guide behaviour of agents within the system (Plamping 1998). These ideas arose from our work discovering what shapes behaviour in a ’self organising’ systems which can help us understand why many structural changes do not generate the hoped for changes. We suggested the rules or guides that kept the NHS the same in spite of many structural reforms and numerous attempts to reform the NHS. To be instantly useable they have to be short and pithy so the rules of thumb in service provision we posited were:

  1. Can do should do
  2. Doing means treatment
  3. Treatment means cure
  4. I am responsible

This approach to understanding systems is akin to Gramsci’s concept of ‘common sense’ (2011) as in ‘that which is held in common and is an expression of hegemonic ideology’. This is not the same as the English language version, which implies ‘good’ sense. It can be understood as the means by which everyday patterns of behaviour are generated by individual social actors rather than imposed by hierarchical controls (although these exist too). In this way of thinking, ideology does not operate through the conscious application of theory or analysis but rather through a series of so-called ‘rules of thumb’. This is a phrase derived from tradesmen making judgments about length without recourse to using a ruler. The phrase suggests practice is shaped, not by direct reference to underlying design principles, but through rules that can be applied in the moment whenever a decision is required. Similar processes of translation from theory into practice are identified in many fields such as social psychology. In Eric Berne’s there is the concept of ‘scripts’ these are the ways deeply embedded assumptions ‘show up’ in behaviour. E.g. ‘hurry up’ is the behavioural prompt to a deeply held but unspoken injunction ‘ don’t think’. Both behaviour rules and underlying assumptions are probably left unspoken – ‘Going without saying because it comes without saying’ [after Gramsci]

Interest in rules that can shape autonomous agents’ behaviour arises from their capacity to shape the outcomes in complex social systems, where decision-making is held in myriad places and by multiple actors. They can be described as the dominant set of cultural rules. There is much interest in the idea of organisational ‘culture’ in change management and organisational development practice. However much of this interest is applied to identifying typologies of organisational culture. Whilst these may be accurate descriptions of what can be observed in a system, they may not be useful in generating change. An alternative approach might be to identify what guiding principles operate in the ‘sub-cultures’ that are always present and where appropriate find ways to for autonomous agents to amplify these and therefore generate new patterns of behaviour a the system. We called this Whole System Working.

The Current Rules of Thumb

In the decades since we posited the original rules they may have been evolving. Reference to ‘long term conditions’ appeared in policy formulations and ideas about ‘living with’ rather than ‘curing’ cancer are now current and there is a struggle between these and the other rules posited above. Despite our recognition of the ubiquitousness of health care practice within teams, we struggle to make find ways to operationalise ‘we are responsible’. So their original formulation may still be useful in generating conversations about service development.

If we were to apply this same way of thinking to current organisational development practice, I suggest we would produce a system which looks like our current public service management if the following rules of thumb were commonly in operation:

  1. Private managers practices are more effective [than public service managers]
  2. Outcomes can be measured easily
  3. Human services are like manufacturing processes
  4. Professionals are always resist change

I would of course reject these guiding principles but I am suggesting they are held commonly enough to shape our public service systems, and we could reflect on how and why previous rules were able to be supplanted. I am itching to offer justifications for why I think they are not fit for purpose but for now I offer these in the spirit of starting a conversation which we could use to generate the rules of thumb for a ‘Twenty First Century public services’.

Diane Plamping

Becky’s Response

Whilst Diane has set out the Rule of Thumb that guided service from the foundation of the NHS, through to the Rules of Thumb that seem to guide the NHS now. I’ve had a go at the Rules of Thumb that we should use for an NHS fit for the 21st Century and beyond. My proposition is that if we used these rules to design services, we would shape a very different NHS. This is my first draft:

  1. Partnering with people as owners secures better health
  2. We are responsible – partnership means everyone contributing [Not I am responsible]
  3. Do what matters to people (health is contextual) and this will reduce demand
  4. If we don’t know what’s going on now we can’t adapt.
  5. Health is relational

My rationale is:

  1. People are coproducers of their own health, and people as owners will contribute to wider service delivery, and help shape services that address their needs. Institutionalisation of health services has gone too far.
  2. If we are responsible then we see health services as collaborative and take responsibility for our part in that. Abdicating responsibility to experts creates dependence and assumes passivity.
  3. The multiple attenders come to GP surgeries and to A7E, they come because their complex health issues are intertwined with their social context. We cant divorce the two.
  4. We need real time data to know what’s actually happening now and as we try out service changes, and new approaches to health.
  5. We heal through relationships, and we generate new possibilities and take action together.

This is an amalgamation of observed rules of thumb in high performing health systems and those teams and systems who are innovating and making an impact in the NHS.

I’d love to know what ‘Rules of Thumb’ you think we need to guide our services.


Berne E (1975) A Layman’s Guide to Psychiatry and Psychoanalysis . Penguin Books Ltd, Harmondsworth, middlesex, England (1975)

Gramsci, Buttigieg, Joseph A, ed., (2011) Prison Notebooks (English critical ed.), Columbia University Press

Plamping D (1998) Change and Resistance to Change in the NHS BMJ 4th July 1998 vol. 317 p 69-71