News and Comment

Making It Better: Manchester’s reconfiguration of maternity, neonatal and paediatric services holds essential lessons about how to lead successful change

Friday 12 December 2014


2014 has been another year of attempts to future proof the NHS. Policy proposals within The ‘NHS Five Year Forward Review’ were welcomed by many, and the recently released Dalton Review on the future of hospitals further challenges NHS leaders to think differently about how healthcare services are organised and delivered. Throughout the past year, CCGs too have devoted considerable time to producing two-year and five-year strategic plans for their local areas.

The ultimate goal of all this future thinking is to create financially viable and sustainable local health systems, but this is more easily imagined than achieved. For if there’s one thing the NHS is good at, it’s planning. Implementing complex change is where things get messy and stalled. Few places have managed to transform local health services without hiccoughs and major setbacks.

Particularly after the election,  2015 should be an watershed year for the NHS – especially for its commissioners. What should CCG leaders be doing now to ensure their plans are achievable? Learning from what others did well – and also from their mistakes – would be a good place to start.

OPM recently completed an evaluation study of Greater Manchester’s ‘Making it Better’ reconfiguration of maternity, neonatal and paediatric services.  Through this evaluation, we have identified some important lessons for CCG leaders and their local partners.

The first observation is that transformational change takes time – and patience. The Making it Better process actually took about 12 years from conception to final delivery.  While there were many setbacks along the way, the programme managed to move from planning to public consultation to implementation by 2007. The reconfiguration of hospital services was completed over five years in 2012.

A tremendous number of people were involved in the delivery of the changes.  Local implementation groups were formed, with task-based delivery groups and clinical advisory groups leading most of the work and taking on clinical accountability.

Governance mattered, too; a programme board was set up, and there were regular meetings between providers and project leaders. The project’s governance structures and processes ensured that clinicians, executive directors and managers across the whole of Greater Manchester presented a united front and worked well together. Governance was crucial to maintaining focus and momentum over such a long period of time.

But what mattered most of all was the clinical credibility of the reconfiguration – both in terms of visible and continuous clinical leadership and the clinical merits of the proposed changes.

There was genuine clinical ownership of the need for change across the whole of Greater Manchester and impartial clinical and managerial leadership for paediatrics, obstetrics and neonatology. This promoted a strong recognition that the need for change was underpinned by a robust clinical argument rather than one of efficiency.

With the continuity of clinical leadership, great effort was put into ongoing engagement of clinicians during the implementation process. Strong clinical participation ensured that care options were underpinned by robust data analysis and supported more widely. A networked approach proved vital; the networks acted as clinical reference groups, and helped to build consensus amongst local stakeholders, such as frontline staff in the respective NHS Trusts.

One of our most interesting evaluation findings concerned leadership capacity building.  Making it better offered many clinicians, senior executives and managers the opportunity to develop new skills and experiences. Being responsible for the safe implementation of the reconfiguration led to personal satisfaction and a strong ethos of commitment to change.

Leaders became adept at managing vested interests. Making it better involved the relocation of inpatient care from some Trusts. Where this occurred clinicians had to balance their personal views with the need for safe and sustainable services across all of Greater Manchester.

Making it better spanned twelve years and took place within a context of great change across the NHS. The disbandment of PCTs and introduction of CCGs led to a lack of continuity on commissioning boards at a critical time in the reconfiguration, as well as turnover of managerial staff, and the concomitant loss of organisational memory.

This situation reinforced our conclusion that the key ingredient for success was the continuity, strength and commitment of the Making it Better clinical leadership team.

Such a dynamic environment will undoubtedly exist for CCGs taking forward their newly agreed strategic plans. Maintaining the momentum locally will require long-term commitments of GPs and their consultant partners. The question is: Will local leaders have the stamina, drive, resources and skills to make a difference to their own local health services?

Part 2: How to resource reconfiguration delivery programmes (to follow)

Download the Making it Better interactive PDF

Download the Making it Better full report