In it together: developing
your local system strategy
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Introduction
Strategy stages and journey
“Now is the time to think afresh, to open up to new ways of working,
and to take the patient perspective – how could we ever justify
working apart when they rightly expect us to work together?”
Organisations tackle strategy development activities in various ways.
The Strategy development toolkit provides a common language and a
logical order for doing this.
Lord Darzi, Implementing the five year forward view: Supporting providers to deliver
Frame
To meet the objectives of the Five Year Forward View and provide the high
quality, seamless, compassionate care patients deserve, it is vital that leaders
across local health systems work on strategy together. The Sustainability
and Transformation Plans (STPs) for the footprints announced in March 2016
emphasise this, as does the devolution agenda set out in the Cities and Local
Government Devolution Act 2016.
We created this booklet after holding workshops on our strategy development
toolkit where many strategy leads urged us to develop something they could
apply directly to the systems.
Diagnose
Forecast
Generate
Options
Prioritise
Generate
Options
Agree
governance
• manage the competing goals of different organisations
• shift from transactional relationships to truly transformational ones
• innovate to tackle long-standing problems when resources are constrained.
Develop local
leadership and
collaboration
It is designed to be read alongside our strategy development toolkit and the
compendium of case studies offered by colleagues in the service.
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Prioritise
Develop and
optimise solutions
Establish
common
purpose
Deliver
Frame
No one we spoke to had solved all these problems, but many were able to tell
us what they had learned from the approaches they had taken and were keen to
share this to help others.
This booklet is our response to what we were told, and shares some of the great
work that is going on around the NHS, and more widely. It provides you with
insights from the service, and signposts you to resources and case studies. We hope
it will be of use to systems whatever their stage of working together.
Evolve
Many of those we spoke to described the journey they have been on with
their system colleagues to develop strategy. We have taken this idea of
a journey and mapped to the toolkit stages. We have also used this to
organise this booklet.
Speaking with health and social care leads across the country, there was wide
consensus that the challenges for systems working together are to: • deliver long-term change while still meeting short-term pressures
Deliver
Diagnose
Understand
future challenges
Forecast
Evolve
Define, implement
and evolve plans
Define system
goals
Engagement across system at every stage
Getting ready
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Strategy development
Planning
and delivery
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Use of language
What do we mean by ‘strategy’?
‘System’ and ‘strategy’ can be used to mean different things. Here we
define how we will use these terms in this booklet.
There are many different definitions of strategy: all of which have virtues/
advantages. We define strategy as ‘a set of principles and choices designed to
help systems achieve their long-term goals’.
Strategy development
What do we mean by ‘system’?
We can think of systems as a network of interdependent components that should
work together to try to accomplish the aim of the system. The aim for any system
should be that everybody gains, not one part of the system at the expense of
any other.
A health and care system will include a number of different organisations
connected by either:
• policy, eg the STP footprints
Strategy development is not a simple linear process. In practice, systems will stall
on, revisit, and adapt different stages of the strategy. The strategy will evolve as
you understand more about the system and situations develop around you.
Strategy development is complex and many factors will be uncertain. An agreed
vision, clear goals and consistent leadership will help keep you on track.
Strategy development is continuous. Different levels of strategic thinking will be
needed depending on what stage your system is at, as shown below:
• patient flows
Which level of strategic thinking is required?
• local challenges
• historical relationships.
The information in this booklet will apply to any of these ‘systems’ – some
sections will be more useful than others depending on the maturity of system
relationships, the track record of working together and particular local challenges.
WHEN?
Systems can be defined by the people working within them and by the people
working outside them. Some systems will have been working collaboratively for
years, and some will just be starting to form relationships.
•Assumptions made
in the strategy still
hold true
•Next stage in
the strategy
implementation
is reached
•Mostly happy with
the strategy but:
–a few changes in
the competitive
environment
–questions to
answer from
the board /
management
•Previous strategy
has run its course
•External
environment is
disrupted
•New performance
issues are
identified
STAGES
STRATEGIC
THINKING
See the ‘Using the booklet’ (page 5) for more information.
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Recommit
to the strategy
Deliver
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Evolve
Refresh
the strategy
Recreate
the strategy
All stages
All stages
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Using the booklet
The booklet is organised according to the stages of the journey shown
on page 2.
Getting ready
• Develop local leadership and collaboration
• Establish common purpose
• Arrange governance
Strategy development
• Understand future challenges
• Define system goals
There are many resources available, and each will appeal differently to
users at different stages of their development journeys.
• Develop and optimise solutions
You can think of these stages as:
Planning and delivery
Emerging
• Define, implement and evolve plans
Early stages of gaining commitment to working together, but this has yet
to start
In each section, we provide:
Embedding
• commentary reflecting the views expressed during our
engagement work
Commitment to working together, but in the early stages
• key questions that systems should consider
Sustaining
• cross-references to the case studies in the appendix. These
are real examples that people wanted to share. They focus on key
learning and advice; many of them are therefore incomplete –
and even those that are more developed will change over time.
Good relationships in place and established track record of working together
• signposts to resources in the toolkit and elsewhere
• top tips
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We expect that systems at the ‘emerging’ and ‘embedding’ stages will find most
of this booklet useful.
Systems at the ‘sustaining’ stage will probably find the case studies and extra
resources most useful, depending on what specific issues have arisen.
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Getting ready
Develop local leadership and collaboration
Establish common purpose
You told us that strategy development should begin with the development
of honest and trusting relationships. Each leader must be equally valued
and understand others’ perspectives if the system is to be really effective.
You told us that groups need to establish their common purpose to
motivate people to stay working together. Sometimes this purpose will be
defined by an issue that arises, eg a financial gap, and sometimes leaders
will need to work together to define their common purpose.
This means having open conversations about histories, each organisation’s
priorities, the shared values and behaviours leaders will commit to living
and role-modelling for others, and the ‘red lines’ no one is willing to cross.
Key questions
Competing priorities are a common problem, but agreeing guiding
principles for working together helps to establish a common purpose.
Key questions
• Have we got the right mix of people in the room?
• Have we agreed the boundaries to our system and who is in it?
• Have we identified the ’elephants in the room’ and do we have a
plan to address them?
• Do we have a shared vision for our system which is specific
enough to create alignment and overcome competing priorities?
• Are we prepared to stand together to lead the system especially
when things get difficult?
• Have we formally agreed the guiding principles for joint working
towards achieving this vision?
Case studies
Case studies
Effective local leadership and collaboration is about building relationships. Read
the case study from:
There are different ways to identify the common purpose that will bring leaders
together. Read the case studies from:
• Birmingham and Sandwell Vanguard Site, the vanguard leaders here
had a meeting where they each wrote down and discussed the ‘red lines’
they simply weren’t willing to cross in the process. From this the leaders
could have frank and honest discussions about what they could achieve
within these boundaries.
Resources
Tools to help assess development needs:
• Coastal Care Partnership in Sussex where at one of the system meetings,
leaders presented patient stories they had sourced from patients and
clinicians. This reminded leaders why they had formed the partnership, and
aligned them to a common purpose again.
• Cambridge & Peterborough health and care system, here the tripartite
team carried out 1:1 interviews with leaders to understand what they
thought success looked like for the system, and what the challenges were.
They played this back to the leaders who could then see the similarities
across their views and align this to a common purpose.
•AQuA: System Integration Framework Assessment
• NHS England’s Sustainable Improvement Team’s Network
diagnostics toolkit and Productive partnering
The Systems Leadership Partnership has a range of tools and resources
on its Systems Leadership Hub.
The King’s Fund’s Practice of System Leadership: being comfortable with chaos.
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Resources
Barry Johnson’s Polarity management approach offers a way of managing
competing aims for mutual benefit.
Michael Porter’s The strategy that will fix healthcare describes how
organisations can align on common concepts of value.
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Arrange governance
Getting ready: Top tips
We were told that strong governance structures are essential, but leaders
often don’t dedicate the time at the beginning to develop these. If robust
structures are not set out upfront, problems will arise later as decisions
need to be made or challenging problems arise.
Develop local leadership and collaboration
Governance should define how organisations hold each other to account,
make decisions and comply with any relevant statutory duties. It should
be defined in a written document that is kept up to date, signed up to by
each organisation and referred back to as necessary.
• Taking people with you through the strategy development process – and it
should be everyone who will be affected by the changes being considered –
takes time and effort.
• For your core system leadership team, balancing the need to be inclusive
with the ability to make decisions effectively can be difficult – you need the
right people to get the work done rather than a lot of people.
Establish common purpose
Key questions
• Do we have/need a formal memorandum of understanding?
• Have we agreed and documented how we will work together, particularly
how decisions will be made and how we will hold each other to account?
Arrange governance
• The process of creating governance structures can itself generate buy in and
commitment to joint working.
Case studies
Systems need to find governance arrangements that work for their particular
circumstances. Read the case studies from:
•The MASH team in Nottingham which used citizen case studies to work
through their governance structures, and identify barriers to those using the
service. From this the organisations developed more inclusive cross-working
practices with clearer roles, responsibilities, and rules on information sharing.
• North West Surrey CCG where each Board member has an equal role and
responsibility for performance is shared across the different organisations.
This culture means members can hold each other to account productively
and support each other through difficult times.
• Robust terms of reference can be useful for resolving disputes – but be
careful, because they can be used as a reason to block change if the
relationships they relate to aren’t working.
Additional resource
The art of change making from the Leadership Centre is a quick reference
guide to a wide range of change management approaches.
The following models will help you understand the types of problems you
are tackling and approaches you can use to solve them:
Resources
•the Cynefin framework – problems are classified as obvious/
complicated/ complex or chaotic
The Future Focused Finance team provides resources and guidance on
decision effectiveness.
•the tame/wicked problem distinction
Managing successful programmes offers guidance on creating programme
infrastructure with clear roles and responsibilities.
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• Make sure your vision is specific and compelling – it needs to be much more
than ‘improving patient care’ if everyone is to align with it. It should focus
on staff and patients, as well as finances.
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Often these responses are as much about engaging people and rolemodelling values and behaviours as they are about technical skills.
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Strategy
development
Understand future challenges
Diagnose
• Are we clear about what drives our performance
today and in the future?
System leaders often struggle to establish a shared understanding of the:
• operating environment
• Do we have an agreed and common view of
activity, finance, workforce and performance
across our system?
• baselines in relation to key challenges for the system
• shared future planning assumptions.
The strategy development toolkit’s Frame, Diagnose and Forecast stages
can all help to develop this shared understanding.
Frame
Key questions
Key questions
• Do we have a shared understanding of the key
questions we need to answer together?
• Have we agreed which are the most important?
Case studies
There are many ways to think about the operating environment. Horizon scanning
exercises can help if they engage a wide range of people. Read this case study from:
•The Like Minded programme team in North West London, that
engaged with a wide range of stakeholders to develop their case for
change for mental health services. They actively listened to stakeholders
experience of services and views on what needed to change. This meant
they had a robust evidence base and buy-in across the system for the
change programme.
Case studies
To diagnose effectively you need to link up data across the system. Read the case
studies from:
• Kent County Council’s Public Health Team, which worked across the
system to develop relationships with clinical commissioning groups
(CCGs), providers and GPs to build a linked dataset across local authority
and NHS organisations Kent. All organisations now share data to inform
system-wide decisions.
•The Leeds Intelligence Hub team who analyse the system as whole;
how it behaves, future trends. They present meaningful information to the
board, who use this to make investment decisions for the system.
Resources
The toolkit gives different methods for this analysis (p64 to 73). These can be
used at the system level if you take a collaborative approach, agree data and
assumptions across organisations, and focus on patient journeys and pathways.
It includes example driver diagrams that can help break down complex
problems so that system components can be identified and aligned. The
King’s Fund provides further resources for and examples of this approach.
Publicly available data:
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Resources
• NHS England’s commissioning for value data packs contain a
wealth of spend and outcome data for local areas
The toolkit gives four methods you can use to develop your strategic
questions (page 45 to 52). It also gives example decision-making criteria
(page 56) to show how these can be applied.
• Monitor (now part of NHS Improvement) produced local health
economy data packs which provide detailed information across a
range of healthcare metrics
Benchmarking data can help identify areas to focus. NHS England has a
comprehensive library of tools and resources.
• NHS England’s outcomes indicator tools
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• Public Health England’s health profiles
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Forecast
Define system goals
Key questions
• Do we have shared planning assumptions?
• Have we agreed what scenarios we need to
plan for?
• Have we agreed the gaps we need to address?
Case studies
To forecast you need to share data and agree assumptions across organisations.
Read the case studies from:
• West Cheshire Health and Care System, which built relationships
and developed trust across providers and CCGs so they could develop a
system-wide long term financial model (LTFM). This provides leaders with an
understanding of the financial position of the whole system.
• The Scottish Future Forum used scenario planning methods to develop
four different world views on how Scotland might develop as a worldleading learning nation. These were developed across government, the
education sector and the business community, to prompt thinking in these
different sectors.
You can access their report here: By 2025, Scotland will be regarded as a
world-leading learning nation.
Resources
Once you have established a shared understanding of future challenges
for the system, development of specific goals helps maintain focus and
provides a measurement of success.
It is important to be clear about the link between system goals and
national policy aims as this strengthens the mandate across the system to
work together.
Key questions
• Have we agreed which of the challenges are the most important to
address?
• Are we clear about why we have chosen these goals?
• Have we agreed how we will choose between different options?
Case studies
To develop shared system goals you need to work with leaders across the system.
Read this case study from:
• Cambridgeshire & Peterborough Health and Care system, here
the tripartite ran a workshop for leaders where they could have open
discussions, in mixed groups, about what services should look like in the
future. The outcome was an agreed high-level design, with clinical priorities
and enablers.
The toolkit provides methods for base case forecasting (pages 126 to 159)
and scenarios, sensitivities and risks (pages 160 to 168) that are applicable
at the systems level if you:
• ensure activity and finance data are measurable for system functions
and risks
• agree that sensitivities and scenario planning reflect all system
partners’ concerns.
Local authority joint strategic needs assessments provide valuable data
on the forecasted future needs of local patients and residents.
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Develop and optimise solutions
Prioritise
• Have we agreed common criteria to assess and
prioritise these options?
Once you have defined your goals, you need to work together to develop
ways to achieve these goals, and pick the best of these to take forward.
Engaging widely across the system will help you develop informed options
that are owned by staff and patients. It is useful to agree the criteria you will
use to prioritise the options before beginning this stage, as this can help to
avoid later disputes.
Generate
Options
Key questions
• Have we decided what we are not going to do?
• Can we articulate simply our combined strategy?
Case studies
The prioritisation process can often cause disputes, but there are ways to
overcome this. Read the case studies from:
Key questions
• Have we agreed how we are going to approach the
system goals? (eg population segments, pathways)
• Have we engaged across the system to develop
options, including with patients and clinicians?
Case studies
Engagement with a wide range of stakeholders is key. Read the case studies from:
• Liverpool CCG, their clinical representatives worked closely with medical
directors across the system to design how ‘one service’ could be delivered. A
landmark agreement has now been made to work towards a ‘Single-service
city wide delivery model’.
• Trafford CCG which worked with providers to design a co-ordinated care
centre for the city. The CCG engaged providers from the beginning and now
has a robust design for the service with buy-in and support from stakeholders.
• Liverpool CCG which used the Future Focussed Finance Decision Making
Framework to define decision making roles across different organisations.
This meant a key commissioning decision could be made quickly without
dispute when it came to the final decision.
• North West Surrey CCG which ran large stakeholder workshops where
attendees developed and voted on options for the system to take forward.
The high number of people involved meant the process was objective, and
the stakeholders were involved in the changes.
Resources
The toolkit provides:
Resources
• templates to analyse the impact of your options
(page 297 to 304) with key principles applicable to systems
The toolkit provides:
• different methods of engaging with stakeholders and generating
ideas (pages 32 to 39)
• templates for analysing options (pages 207 to 213)
• case studies on delivering services differently (page 214).
Information on progress on new care models is available on the NHS
England website.
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• three horizons tool (page 172) which is also useful for mapping
your initiatives over time
• balanced portfolio which sets out the risk and intensity of resource
initiatives (page 317 to 318)
• examples of strategy on page (page 320 to 325) – putting your
strategy on a page is a crucial communication tool.
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Strategy development: Top tips
• Having a good understanding of your technical data is important – but
analysis can lead to paralysis and is sometimes used to block progress.
It’s worth agreeing how much analysis is enough for your purpose, and to
cross-check findings with non-technical data sources.
• Don’t pick too many things to work on – choosing what not to do is as
important as choosing what to do.
• Improvement science methodologies can be really helpful for thinking about
how to review and design services. The principles are simple:
– understand the process to be improved, end to end and step by step
– measure what matters to the quality of the process
– analyse demand, capacity and flow along the process, to see how
variations in demand affect flow for a given capacity.
– reduce any waste, errors and defects to make the process more
reliable
– engage all staff who make the process happen, clinical and non-clinical,
in all the stages above. All staff working in a process have the right and
the responsibility to improve its quality
– involve patients, carers and the wider public in designing how to
improve the process and then monitoring if improvement is made or not.
There is no one right way – what matters is that you pick one and own it.
A useful starting point for understanding different approaches is The Health
Foundation’s Quick guide to quality improvement.
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Define, implement and evolve plans
Evolve
• Do we have a clear approach to measuring the
impact of our plans (clear KPIs and escalation
and resolution procedures)?
Even when system strategies are agreed, progress can slow down if there
is no clear, shared approach to programme delivery. This requires clearlydefined and allocated activities.
Deliver
• Do we have a culture and approach will
allow us to adapt our plans to the changing
environment?
Key questions
• Do we have a clear plan, with milestones,
assigned owners and appropriate resources?
• Are we clear what changes we need to make to
current working practices to ensure success?
• Have we established a shared programme
delivery management office with appropriate
governance structures?
Key questions
Your strategy will evolve according to the requirements of your local system. As
outlined at the start of this booklet, strategy development is a continuous process
and evolution will sometimes involve:
• recommitting to an existing strategy
• refreshing it if the environment has changed
• recreating it if the environment has significantly changed.
Evolution will be easier if there is strong leadership and a culture where staff:
System cultures that are honest, resilient and agile will have the best chances
of success.
• everyone needs to take responsibility and be held to account for the actions
they agree to complete
• resources should be clearly identified and fairly allocated – this may
require re-prioritisation of existing work
• outcomes should be defined and captured in appropriate system-level
key performance indicators (KPI)
• system leaders should regularly review progress and adapt approaches
to meet changing needs.
• are involved in defining and committed to a clear vision for their local area
• have clear priorities and objectives that are linked to system performance
• are treated consistently, inclusively and with compassion
• are continually learning, improving quality and innovating together
• feel connected within and between teams across the system.
Resources
The toolkit has some applicable tools on culture change, behaviour
change and communication strategies (pages 347 to 352).
It also has some examples of strategy triggers (pages 359 to 361) and
developing a contingent roadmap (page 363) that will be applicable to
systems strategy.
Resources
There are also some useful tools for testing the strategy:
The toolkit has some useful SMART KPIs (page 330) and examples of
performance tracking (pages 336 to 340) that are useful for delivering
systems strategy.
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• ten timeless tests tool (page 372)
• testing the strategy development process (page 368)
• common pitfalls (page 371).
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Planning and delivery: top tips
Define, implement and evolve plans
• Make sure you have a good communications plan for your strategy –
get expert help if the changes are going to be controversial.
• Create shared learning spaces to allow those leading and managing
change to think and make sense together.
• Make sure that the affected workforces are actively engaged at every
stage of delivery – keeping people on board is hard work, and the time and
effort required from senior leaders to do this shouldn’t be underestimated.
Contact details
If you have any queries or feedback please contact:
[email protected]
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Contact us
NHS Improvement
Wellington House
133-155 Waterloo Road
London
SE1 8UG
T: 020 3747 0000
E:[email protected]
W:improvement.nhs.uk
NHS Improvement is the operational name for the organisation that brings together
Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and
Learning System, the Advancing Change team and the Intensive Support Teams.
This publication can be made available in a number of other formats on request.
© NHS Improvement (April 2016). Publication code: IG 07/16