Sustainable Development in the National Health Service (NHS)

Short abstract

This article presents the first systematic picture of United Kingdom National Health Service (NHS) leaders' views of priorities and approaches regarding sustainable development (SD). Survey and interview responses are drawn on to show the importance of SD and ways forward.

Abstract

This article presents National Health Service (NHS) leaders' views of priorities and approaches regarding sustainable development in the NHS. It was produced in close collaboration with the United Kingdom (UK) NHS Sustainable Development Unit (SDU), and it represents the first systematic picture of leadership views in the NHS. It also provides a commentary on ways forward. Analysis draws on results of a survey of 172 leaders of NHS organisations (primarily chief executives), 12 follow-up interviews, interviews with the SDU, and additional data and literature searches. A major conclusion is that almost all leaders consider sustainable development to be important for the NHS and that a focus on sustainability can most likely be aligned with delivering other corporate goals. Aligned incentives at all organisational levels and support for diversity are considered necessary to achieve sustainability, as well as relevant performance metrics. The main barrier is organisational culture.

In this first systematic exploration of their views and values on sustainable development and future proofing the NHS, we surveyed 172 NHS leaders, representing a broad cross section of the English NHS. We followed up with twelve interviews. We then compared and contrasted the findings with what we found among leaders from outside the NHS. This article describes the key findings.

There is strong support for delivering a high quality, sustainable NHS; a firm belief that sustainability is part of delivering corporate goals; and a more general awareness of current NHS policies and practices on sustainability.

There is widespread and strong support for delivering sustainability among NHS leaders. Almost nine out of every ten leaders actively engage with sustainability and believe it to be important, a view supported by more detailed interviews. A similar proportion agreed with the NHS Sustainable Development Unit's (SDU) definition of sustainability as: “the needs of [patients and public] today are met, without compromising the needs of tomorrow.” Over 60% of leaders believe that sustainability can help them deliver corporate goals. We conclude that the core messages of the NHS SDU are understood. We also show that leaders' responses vary from one NHS organisation to another, and that there is no shared “one size fits all” to delivering sustainability in the NHS. NHS leaders have thought carefully about the issues around sustainability and use their experience and reflections to inform coherent accounts of how to deliver change in the NHS. 60% of leaders consider themselves to be fully aware of current NHS policies to deliver sustainability, and see themselves as being generally knowledgeable about sustainable development efforts in the NHS.

Organisational culture is widely seen, by 55% of leaders, as a barrier to improving sustainability, with 83% of leaders agreeing that incentives and local diversity are necessary to progress more rapidly towards a sustainable NHS.

Leaders have a variety of views about barriers to delivering sustainability, largely reflecting local organisational circumstances. However, a more consistent view is that NHS culture is a barrier: 56% of NHS leaders feel that they have the necessary formal legal powers that they need to make and implement decisions regarding sustainable development. However, the roles played by other NHS decision-makers and staff regarding sustainable development may prevent leaders who would like to drive the sustainability agenda forward more ambitiously. Meanwhile, the 83% of leaders who regard more obvious (and perhaps more aligned) incentives as necessary are clear that these are wide ranging, including the satisfaction derived from securing financially aligned incentives, improved outcomes for patients, as well as reputational incentives (which might also be seen as “motivations”). Incentives are seen to be most important for Directors and Board members. Many areas are perceived by leaders to need particularly concentrated focus, for example the broad areas regarding changes to pathways and models of care; working with other groups and organisations; and infrastructural changes. Equally, there is no consensus about which areas offer the easiest opportunities. We summarise this leadership view as: “sustainability is delivered through culture change, re-balanced incentives, and exploiting the particular win-wins locally.”

Leaders not only consider that decision-makers in the NHS are unable to share best practice to spread effective action but are also uncertain how to deal with this.

Less than half of the survey respondents agree or strongly agree that decision-makers are able to share best practice to spread effective actions for sustainability across NHS organisations. Furthermore, only around one third agree that staff are sufficiently aware of or engaged with issues regarding sustainability to support a sustainable NHS. Leaders are uncertain whether the best way to deal with this is to appoint a responsible individual (with the risk that sustainability becomes “someone else's problem”) and/or to support Board, executive team, clinicians and other staff more at a whole organisation (or even whole system) approach to help achieve large scale change collaboratively and culturally.

Interviewees add richness to the survey findings about “locking in the moral imperative with the economic imperative” (linking together the multiple win-wins).

There was a strong feeling that a leading societal position for the NHS with respect to sustainability could only be achieved with a sound understanding of individual and organisational behaviour change. We were told of creating a sense of purpose: “locking in the moral imperative with the economic imperative” and communicating this through the organisation and to external partners. There appears to be a strong need to recruit and empower the “guiding coalition” within the organisation of the “brightest and best.” And we learnt about the benefits of partnership across the local health system: working to secure improvements in food supply, energy use, transport and reputation.

Sustainability is believed to support two crucial corporate goals of staff engagement and creating a caring culture.

In particular, it was said that in difficult times for the NHS, sustainability offered an opportunity to engage staff and both reinforce and clarify a sense of organisational purpose and values. Expressing care for both present and future generations was seen to be an effective way to build a culture of care to deliver improved healthcare services today.

Metrics matter and incentives must be aligned, and at the right level.

Interviewees emphasised “metrics are vital or everything else is well-intentioned hot air.” We were told of the importance of “sentinel metrics” that could identify key dimensions of activity and measure progress. It was also said that like all metrics, these should be low cost and easy to collect. At least some of these should be oriented towards identifying the basis for incentives and these should be visible, culturally appropriate, and at the right level (for example, the individual staff member might be too narrow and the department too wide but the ward “just right”).

Lessons from other sectors need to be treated with care but some themes are key; delivering sustainability requires very substantial pan-organisational commitment, close links to the values of the organisation via effective staff and partner engagement and communications, and effective, aligned use of performance metrics and incentives.

The literature from beyond the NHS on leading for sustainability identifies many insights but there is no one single obvious model that should be adopted by the NHS. The difficulty of importing approaches developed in other sectors strengthens the belief that “sustainability in healthcare represents a particularly challenging undertaking as it necessarily encompasses the wide variety of facilities, operations and activities in a typical healthcare organisation.” However, although there is no single approach, successful case studies suggest that delivering sustainability is eminently possible albeit requiring substantial organisational commitment. Sustainability cannot be delivered “at the margins” or as an add-on.

Two themes from the wider literature were less apparent in this study of NHS leadership's views: training and standardisation.

NHS leaders support the aim of linking sustainability to core delivery and use a range of approaches to achieve this. However, these approaches do not yet typically include at least two approaches pursued with success in other sectors; standardisation and training. One possible focus of such standardisation would be around the evidence of alternative models which leaders identified as being helpful.

Our overall findings are summarised in Table 1.

Table 1.

Issues and Related Recommendations for Delivering Improvements in Sustainability

Key Finding	Survey	Interviews	Wider Sources	Recommendations
NHS leaders identify a mandate for action on sustainability, agree with the NHS SDU's definition of sustainability, and believe leadership has a crucial role	Most NHS leaders believe sustainability is important to the NHS and 89% agree with the NHS SDU's definition of sustainability in the NHS 62% of NHS leaders believe it to be compatible with or supportive of wider goals	Leaders personally believe sustainability to be important and not just a “boutique” activity	Leadership is seen to be crucial to delivering complex changes such as moving towards a more sustainable NHS	Leaders are now engaged with and understand sustainability issues. For the future they need support in using knowledge of individual and organisational change to deliver corporate aims through meeting a sustainability agenda
Organisations need support to exploit local entry points and opportunities	Leaders identify different priorities and barriers apparently according to local circumstances	Leaders provided many accounts of the diverse ways they organised and how they drew upon local resources and opportunities	Leadership approaches need to vary according to local circumstances	Since being adaptable to local circumstance is crucial to success, local leadership requires not only the capacity but also the freedom to craft local strategies
Staff culture and engagement remain key to delivering a sustainable NHS	Staff culture and awareness and weak learning are more of a barrier than limited formal powers (56% of leaders believe they have the necessary formal powers)	NHS leaders have well-developed understandings of how to change culture and improve learning	Evidence from the corporate world suggests that changing culture requires sustained and substantial leadership attention	There is already a requisite variety of ideas within the NHS and beyond to support innovative approaches to sustainability. Maximising learning from existing knowledge may be more fruitful than creating new approaches
Incentives must align motivations with performance measurement	83% of NHS leaders believe that incentives matter but that these are more about organisational and patient benefits than personally acquired rewards for staff. 36% of leaders believe that incentives are especially important for Directors and Board members. Measurement and metrics are said to be key to success	Incentives might be symbolic and rewards should be focused on benefits for patients and targeted at an appropriately sized group. Lean thinking is one way to align organisational benefit with sustainability	Performance measurement is identified as a key component of successful moves towards sustainability by health organisations (Boone, 2001)	Incentives should be as much about wider motivations as personal rewards and should be crafted to support the desired cultural changes (for example, improved patient outcomes were seen to be an incentive). These should be measured and visible and should be considered for Directors and Board members
Achieving sustainability requires acting on multiple fronts in the long run but may benefit from more focus at any one time	NHS leaders have strongly held views about the challenges they face and the best way to address these. There is a variety of approaches across the NHS at any one time	Embedding sustainability took different forms and these reflected leaders' deeply held views about leadership and delivering change in their organisations	More sustained efforts to shift organisational behaviour in the corporate sector might have to be adapted in the NHS to support a requisite variety of approaches	Leaders need to be flexible to seize short term opportunities but also aware that in the long term action across a range of dimensions will be needed