How we get there: supporting individual and organisational development

Individual skills and capabilities

Systems need both responsibility and capability to drive reform. The evolving healthcare landscape demands leaders capable of making and implementing challenging decisions while wielding sophisticated analytical capabilities to drive evidence-based change. These individuals must develop advanced skills in data analysis and interpretation, alongside the diplomatic abilities needed to build and maintain effective partnerships across complex systems. 

Data analysis is essential to realising a proactive care model and driving productivity. However, ICBs have argued that they need enhanced capability and capacity to do this as effectively as possible. For example, this has come up following delegation of pharmacy, optometry and dentistry commissioning and specialised commissioning. Efforts to invest in and improve capability and capacity have been hindered in many areas by the 30 per cent reduction to ICBs’ running cost allowance. 

Diplomatic skills will also be essential to realise more collaborative working and allocative efficiency. Strategic commissioners will need to be more relational, strategic and collaborative in the way they work with providers, the VCSE sector and local authority partners. This 'one team' approach needs to be evident at all levels, creating a unified culture that supports genuine integration and collaborative working. Strategic commissioners will need to be expert facilitators to bring community insights into the design of new models of proactive care to achieve the outcomes through early intervention and prevention. Developing strong persuasive skills will be key to this. 

System leadership, built on an understanding of complex adaptive systems, is crucial to building cohesive teams that transcend traditional organisational boundaries. Individuals should be supported to become effective system leaders and given the time and space to build relationships effectively. This requires combining strategic thinking with entrepreneurial action, fostering innovation while maintaining a holistic view of system needs and opportunities. Future leaders will need to prioritise system benefit over individual organisational gain, consistently asking how they can support their system partners. This may involve holding contradiction and uncertainty. The NHS Confederation offers specialist programmes and consultancy services to advance leadership capability and embed improvement approaches across health and care.

Contract management expertise should evolve to encompass both traditional transactional approaches and new models of transformational pathway commissioning. These technical skills need to be underpinned by a deep understanding of how to commission across entire pathways rather than individual services.

Estate management capabilities will become increasingly crucial for system transformation, moving to new estate models and unlocking value from existing underutilised assets to reinvest in future needs, as identified in the Naylor review. The NHS Confederation has already proposed devolving expertise, resource and assets from NHS Property Services into systems to do this, with any remaining functions that need national scale absorbed into NHS England.

Organisational development

Organisations must develop robust change management capabilities to maintain stability during transformation, while evolving their operating models to support new ways of working. This includes building mechanisms for cultural development and establishing effective peer review processes that support continuous improvement and learning across the system.

The focus needs to be on developing new approaches to working across traditional boundaries, creating structures and processes that enable genuine collaboration between different parts of the system. This requires organisations to fundamentally rethink how they operate, moving from siloed approaches to truly integrated ways of working. 

National and regional bodies as well as organisations at system, place and neighbourhood levels will need to consider how they must shift their ways of working to make strategic commissioning a reality. To support system-level organisational development, the NHS Confederation proposes a strategic commissioning forum to help leaders learn from each other and drive forward organisational development at pace.

Case study: Working across organisational boundaries towards common goals in Sweden

Sweden's Jönköping Region built its internationally recognised healthcare improvement programme on a foundation of trust and shared purpose across organisational boundaries. Their ‘Esther’ model, focusing all partners on common patient-centred goals, has delivered sustained improvements in care quality and efficiency.

Case study: Bedfordshire, Luton and Milton Keynes’ Primary Care Workforce Programme

The BLMK Primary Care Workforce Programme is a large-scale holistic programme that supports its primary care providers through a large-scale holistic programme, including: 

• developing learning organisations where staff are supported and empowered to learn and train together and development is prioritised.
  
  
• culture and organisational development, where workplaces embed the ingredients to attract, retain and nurture staff.
  
  
• leadership development where staff develop the adaptive system leadership competencies and behaviours to support system-wide transformation.
  
  
• integrated neighbourhood working, empowering our workforce to connect and build relationships across organisational or professional boundaries within their neighbourhood.

Nationally – direction, stability and knowledge sharing

At the national level, leadership will increasingly involve clear objectives and identifying opportunities for standardisation and efficiency through 'do it once' approaches. These objectives should be consistently framed in terms of population health outcomes rather than traditional activity metrics, creating a clear line of sight between national priorities and local delivery. The national tier has a crucial role in delivering priority projects at scale, leveraging its unique position to achieve NHS-wide value. This includes using national purchasing power and establishing frameworks that enable local systems to focus on implementation rather than reinventing common solutions.

Elsewhere, the national level should seek to support systems in areas where they ask for help (a service model) and continue to devolve functions, responsibilities and capacity for functions that can better be delivered at a more local level, closer to populations. Resources should be aligned with ambition, supported by integrated regulatory functions that enable rather than inhibit change. This requires a careful balance between maintaining national standards and allowing local systems the freedom to develop approaches that work for their populations and circumstances.

National policy must provide the structural stability necessary for local reform to flourish, maintaining consistency in policy approach while reforming oversight mechanisms to support system working and empowering ICBs to drive change. This stability needs to be balanced with sufficient flexibility to allow local systems to innovate and adapt to their specific circumstances.

At system level

Systems are responsible for setting comprehensive strategies that encompass all aspects of health and care delivery within their geography, working collaboratively to agree local priorities that reflect both national requirements and local needs. This strategic role requires building strong relationships across all system partners.

The focus at system level should be on developing effective system leadership and fostering a 'one team' approach that brings together all partners in pursuit of shared goals. This includes creating structures and processes that enable genuine collaboration and shared decision-making.

ICSs should increasingly use peer review to laterally drive change and be supported and encouraged to do so by national policymakers. Peer review has long been an effective driver of improvement in local government.

At place and neighbourhood

At place level, the focus is on tactical implementation of system strategies, turning high-level plans into practical actions that deliver real change for local populations. This includes commissioning at place, enabling effective collaboration between local partners and supporting the development of primary care networks and collaboratives.

Place-based leadership has a crucial role in driving neighbourhood integration, ensuring that services work together effectively at the most local level. This includes supporting the development of integrated care models that respond to local needs and preferences while maintaining alignment with system priorities. Neighbourhood healthcare should:

1. provide wraparound care for those who need it more
   
   
2. promote health and wellbeing and improve the relationship with communities
   
   
3. increase community resilience.

The ten-year health plan will need to clarify the vision for neighbourhood health to inform local implementation.

Making change happen: three stages of changes

Sir Michael Barber suggests three stages to changing behaviour to deliver public service reform, supported by development at three levels that may guide the development of strategic commissioning in practice. 

Stage 1: Awareness raising

Develop a comprehensive understanding of strategic commissioning's role in system transformation, while building a shared vision of the desired future state. Through collaborative engagement, systems work to define a clear and compelling case for prioritised changes, creating the necessary momentum for transformation across all partner organisations and stakeholders. 

Stage 2: Formal training

Build the essential capabilities required for effective strategic commissioning, encompassing the development of sophisticated data and analytical skills alongside strengthened relational leadership capabilities. This includes enhancing expertise in contract and pathway management, while supporting the development of new competencies that enable staff to work effectively in more strategic and collaborative ways across traditional organisational boundaries.

Stage 3: Embedding through learning and culture

Establish sustainable mechanisms for continuous improvement through the creation of peer review processes between systems and active learning networks. By sharing successful approaches and embedding an improvement culture, systems can sustain positive changes through collaborative working. This creates a self-reinforcing cycle of learning and development that supports ongoing system evolution and improvement.