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