A mindset of ambition – the quantum leap we need

As we move towards the adoption of a new model of health and social care, is the scale of our ambition too limited? Are we frightened of the quantum leap that’s really needed?

The former General Electric chief Jack Welch once said: “Shun the incremental and look for the quantum leap.” As we move towards a new model of health and social care, is the scale of our ambition too limited? Are we frightened of the quantum leap that’s really needed?

To genuinely recalibrate our activities around the citizen, to create a more holistic and sustainable model and then use it to meet the challenges we face as a nation, do the integrated care proposals aim high enough?

Failure of ambition

We're in danger of being complicit in a huge failure of ambition – at precisely the time when collective ambition is what is needed most. We're limiting what can and should happen by focusing only on what we feel can 'realistically' be done. But are we using this perceived realism as an excuse for not stepping up?

The NHS is understandably preoccupied with the mechanics and consequences of centralised reform and the complex bureaucracy that currently makes up governance and the related regulatory climate.

But the broader challenges we face, particularly around supporting civic renewal and addressing sustainability, require something much bigger. What’s needed is a shift of power and resources at a scale and pace that will not happen under current rules with current mindsets.

We comfort ourselves with narratives about the role of citizens, place and community. But there is nowhere near enough investment to grow community strength, cohesion and participation to make them credible and sustainable.

And we accept this. We pay too much heed to the cautions from historical precedent and to the complexities involved in radical reform to do anything other than make incremental change.

At a time when radical shift is needed in thinking and doing, to do justice to the times and the opportunities they provide, is our collective risk appetite around reform simply too tentative and calibrated wrongly?

Raising our sights

We believe it is not too late to set a greater ambition to reach beyond the rather tame version of place that will result from implementation as things stand.

The current vision for integrated care is to support greater involvement of the community in the work of civic institutions with an emphasis on engagement, co-production and voice. And that’s all good, but it’s not enough.

We must redefine the citizen's role in decision-making and resourcing decisions. We must set urgent timescales for transferring power and resources. We must find the courage to invest in the face of other priorities in non-statutory institutions and risky projects. And we must build a much greater understanding of what building assets means.

This would give us a new model of place-based stewardship in which citizens can be authoritative. It would be the basis for a new contract between citizen and state.

Higher standards

We must also set higher standards for public life – and ensure there are genuine consequences if those standards are not met.

At a time when the country is gleefully preoccupied by the probity of the refurbishment of 10 Downing Street, it is tempting to focus these efforts on traditional Westminster sleaze, but this is broader than that. It extends beyond the national stage to the regional and local – it is closer to home than we are sometimes prepared to admit.

Implementing the integrated care reforms must surely involve setting stronger standards for professional leadership and governance. For example, we need to acknowledge our complicity in some of the poor leadership we have seen from clinicians. Are primary care networks really the right vehicles to meet governance standards? We must also bring about a power shift that puts public and mental health at the front of the stage – perhaps at the expense of acute care. And we must remain focused, throughout, on good governance outcomes.

Part of the necessary ambition is about making a quantum leap as a community of leaders:

• to use good governance to foster a grounded ambition – to ensure we’re not just talking about change and failing to deliver it
• to do the right thing – not just say or think it but actually do it now for the long-term – which is, after all, the essence of good stewardship
• to create new forms of local accountability – through the informal as well as the formal – that really stick
• to give away some authority to create greater legitimacy
• to focus on broader issues of public protection and mobilisation of resources
• to take the opportunities that exist, irrespective of the mechanics of the reforms.

What are we afraid of?

Today’s illumination is designed to provoke a broader and deeper debate around integrated care and the public sector in this country.

We recognise that radical change happens when inspired and inspiring individuals break a mould – as Beveridge did with the British welfare state and Bevan with the National Health Service. When multiple agencies are involved, there is a tendency for collective concerns to smooth out the rough edges and pull thinking into a moderate, compromised middle ground.

It takes real courage to embrace a fundamentally new mindset and up-end the status quo. But we all recognise that change is needed. We all know that the current model is unsustainable. So perhaps we should start this long and difficult journey by asking ourselves: what is it that we are so afraid of?

Illuminations

• On its own, the integrated care legislation will not be enough to bring about the changes we need – NHS boards and their counterparts in social care, local government and across the public, private and third sectors would do well to find ways to work together, take the initiative and step up to this great challenge.
• We should start with a clear, shared vision of what integrated care is, what it can achieve and why it is better than what we have now; this needs to be clearly articulated and widely shared.
• These questions extend beyond integrated care into the broader realm of public governance in the decade ahead – we must recognise the long game we are in, shun timidity and take the quantum leap that is needed.

If you have any questions or comments about this briefing, please call us on 07732 681120 or email advice@good-governance.org.uk.

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