I want to introduce you to three people. Stanley is a US Navy general. He’s 49, jogging in Iraq’s searing heat. Jean-François is a French industrialist. He’s just climbed out of his boss’s helicopter to be announced as the new Chief Executive of a brass foundry. Jos is a Dutch community nurse. He’s just quit his job. So has his wife. They have savings (small) and children (five).
Together, these three can help save our health services.
Let’s start in Iraq. It’s 2004. General Stanley McChrystal has just been appointed as Commanding General of the Joint Special Operations Command of the US Military. Unfortunately, it isn’t going well: the highly honed processes, and technological supremacy of the Task Force is being beaten by an insurgency of fighters with barely enough training to be called soldiers. McChrystal realised hierarchical decision making and information shared on a ‘need to know’ basis was holding them back. The Task Force was built to operate in a linear world, while Al Qaeda’s adaptability meant it was able to thrive in the wildly unpredictable nature of the post-Saddam Iraq.
In response, the Task Force learnt from their foes and transformed into a ‘team of teams’ – a network where information was shared far more readily, and individuals empowered to use their judgement. McChrystal made relationship building his top priority; sending his best people to partner organisations to show he valued their relationship, and starting daily teleconferences (attended by 7,000 people) to share intelligence amongst his teams and beyond. The changes worked; by 2006, with minimal increases in people or funding, the Task Force was able to carry out seventeen times as many operations than it had been able to two years previously.
We next come to Jean-François Zobrist. It’s 1983. He has just been appointed Chief Executive of FAVI, a small French brass foundry. Zobrist inherits an organisation of 80 people arranged like a pyramid, but within two years has turned the company on its head. In place of hierarchy are a set of self-organising “mini-factories”. There are virtually no rules or procedures other than those decided by the teams themselves. The store cupboard, previously requiring supervisor permission to open, is permanently unlocked. When Zobrist stepped down in 2009, all of his European competitors had moved to China. FAVI however now employed 500 people, was able to pay its workers above market rates, and still made a healthy profit.
Finally we come to Jos de Blok. It’s 2006. Jos has been a community nurse for 25 years. He’s just quit his job because “I got more and more frustrated when I saw how a lot of patients clearly suffered from the way we organized things.” He started his own company, Buurtzorg, without top down hierarchy or strict schedules, but small autonomous teams. Rather than a mandated 2 ½ minutes to change a stocking, Buurtzorg nurses started sitting down with their clients, having coffee, and listening to stories. Buurtzorg now employs over 7,000 nurses and is being exported to countries (including the UK) around the world. Furthermore, studies have shown that Buurtzorg teams are able to deliver better outcomes than their competitors on 40% fewer hours of care.
Why am I telling you this?
Stanley, Jean-François and Jos all ran organisations which needed to be able to innovate fast, spread learning rapidly, and establish strong links inside and out of their organisational boundaries. The critical ingredient identified by all three was trust: between different levels of seniority, between internal teams, between the organisation and its partners. There’s a considerable evidence base across a wide range of industries that high levels of trust are fundamental to building organisations that are able to adapt and thrive; the Task Force, Buurtzorg and FAVI represent the tip of the iceberg.
In 2016, our talk is full of deficits: insufficient money, lack of staff, quality shortcomings. What we don’t talk about is our considerable deficit on trust. It is concerning that only 7% of NHS staff in England strongly agree that their organisation fairly treats staff involved in errors, near misses or incidents. Equally, the increased level of ‘grip’ from national organisations (In England at least) upon local bodies speaks of a system focused on fear and blame far more than trust and support.
Without radically higher levels of trust, it seems nigh on impossible for our health and care services to becomes the learning systems so desired by many (including Jeremy Hunt), or be able to generate anywhere near the efficiencies demanded by the UK's respective Treasury departments.
So where do we start? Building trust is not an intangible beyond the reach of concerted action. Nor is it just about policymakers taking regulations away; building trust equally requires significant focus on organisational development, communication systems, and the development of networks.
This is where the UK Improvement Alliance has the potential to make a significant difference. While our eight founding members contain a disproportionate amount of the UK's improvement expertise, knowledge alone will not enable the Alliance to learn and improve at the rate required. Fundamentally, our success will be determined by how much we trust each other - both to share what is going well, but critically to create a space of psychological safety where we can show vulnerability, be honest about our challenges, and have the humility to learn from others.
The stakes could not be higher: trust is a key element to health services across the UK overcoming their daunting challenges. Without it, we're sunk. With it, we might just have half a chance.