"What does 'good' look like?"

Lately I've been doing some work in the NHS. Being a new boy, I have been trying to gen up: I went to a thing at the King's Fund headquarters last Thursday night. I came away encouraged. The thing was Samantha Jones being interviewed by Roy Lilley. Samantha is a new-mould, rising-star NHS manager and head of the NHS’s New Models of Care programme. Roy is a long-time NHS-er, now commentator, and probably its most clamorous critical friend. It was entertaining and interesting. Roy was sparky and challenging: Samantha, open and honest.

The New Care Models initiative is about generating innovation in care. Its instruments are a collection of locally-managed projects called Vanguards. (Roy called Samantha the Vanguardista.)

The stand-out bit for me was when Samantha was explaining the Vanguards. Roy asked, "What does 'good' look like?” I imagined he was prompting a description of some future state against which success might be judged. But Samantha didn't answer that way. And Roy asked the question again - several times - in an 'every worth-their-salt manager should be able to describe where they are going, surely' sort of way. Samantha explained it was for the people at the local level to work out what was good and get on and make things so. And she stuck to her gun. Spot on.

When senior managers define the future, those below naturally want to deliver it. This works fine when the future is mostly knowable: it doesn’t when it’s not.

The NHS needs to change significantly. Its principal challenge of looking after the elderly cannot be met by being good at running hospitals. There is a need for an unprecedented coming together and change in mind of all those involved in caring for people: clinicians, social care staff, volunteers, families and (not forgetting) ourselves.

This is a complex puzzle. Whilst many can imagine how parts of it might be done differently, how the whole will come together cannot be known. If it were, McKinsey or their ilk would have had it wrapped up yonks past. The Vanguard idea, following its military forebear, is about probing and finding the way. It is quite different to the linear analyse-strategise-realise approach to public sector change we are used to.

Samantha's instincts are right. But it's not enough for just hers to be right. For change this profound, it's important that those instincts pervade. Like zooming in on a fractal image, the pattern must repeat at whatever organisational scale it is viewed. We must, recursively, put finding out what 'good' looks like in the hands of those closer to the action than us.

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