Busting Bureaucracy in health and social care: understanding and leading cultural change to solve a complex problem

It is hardly breaking news to note that many feel the level of bureaucracy in the English health and social care system is too high. We know that bureaucracy grows in large, hierarchical organisations, and the health and care system in England employs over 3 million people (1-in-10 of the working age population). The NHS sees 1 million patients every 36 hours, while local authority funded adult social care supports over 800,000 people a year.

While rules and guidelines can be vital to managing risk and ensuring safe, high quality care, the rapid adaptation necessitated by the COVID-19 pandemic over the past year has shown that when excessive bureaucracy – the ‘barnacle-like encrustation of rules and regulations’ – were stripped away, empowered staff had more time to prioritise care and innovation flourished across the health and social care sector.

Covid has shown that if you give a system a single goal to rally around and give trusts and systems freedom to do what’s needed to reach that goal, you remove some of those blocks to operating well and see better performance. – NHS Providers

These were the key findings of our recent report, ‘Busting bureaucracy: empowering frontline staff by reducing excess bureaucracy in the health and care system in England’, which was the result of an extensive listening exercise with frontline health and care staff launched in June by Secretary of State for Health and Social Care Matt Hancock. Through a call for evidence, in-depth interviews, and a series of focus groups with frontline staff (delivered by Research Works), we received contributions from more than 600 people with their real-life examples of excess bureaucracy they faced in their day jobs. 

We also reviewed previous bureaucracy busting literature and received input from a wide range of other stakeholders in the health and care system, including professional bodies, commissioners, academics, patient groups and providers to come up with a clear set of recommendations and actionable next steps tied to the lived experiences of frontline workers.

What we heard from the frontline

COVID-19 has caused a radical shift in the way people work in health and social care. Local and national healthcare leaders have introduced changes within weeks that have been talked about for years. Managers and regulators have paused some data requests and streamlined inspections, liberating and empowering frontline staff to focus on delivering the best care possible.

The last five months have empowered leadership teams across all sectors and the nonexecutive community to make dramatic changes to the way they operate. [This has] sharpened and accelerated decision-making and radically altered NHS working cultures. – Lean, light and agile, NHS Confederation (2020)

Through our evidence gathering, we heard many stories of positive change, including:

• NHS England and NHS Improvement, together with Academy of Medical Royal Colleges, the GMC and the British Medical Association have introduced a new streamlined appraisal process, reducing prep time length from on average 5 hours to 30 mins;

• NHSX launched the Information Governance online portal in October 2020 to host simplified IG guidance (including COVID-19 IG guidance) for patients and service users, health and care staff and IG professionals; and

• The Care Quality Commission is actioning a new style of regulation through the introduction of its Transitional Regulatory Approach building on its successful “Emergency Support Framework” used over the summer.

One standout example of where locally-driven change made a real impact in busting bureaucracy came to us from the East London Foundation Trust (ELFT) in a campaign they ran long before the pandemic, called ‘Breaking the Rules’. In a March 2017 display of open culture and strong leadership, ELFT encouraged all staff to “break the rules” so they could focus on what is valuable to service users, carers and staff. Their campaign aimed to cultivate a culture of constructive challenge, transparency and continuous improvement. Over 100 unique ideas for cutting red tape were submitted, with 600 staff voting for their favourites; about 2/3 of the ideas raised were not actually rules, so myth busting was an important aspect of the programme. These ideas were then implemented by senior management.

These stories and examples were encouraging, but in order to ‘bottle’ this change and make it endure, it was important for us to understand exactly how and why those changes occurred.

The root of the problem and our proposed areas for action

No matter where the bureaucracy was coming from, or in what form it manifested, everyone we spoke to could identify the same factors: hierarchy, culture, trust and leadership. These lead to a huge number of secondary drivers and symptoms as the more tangible day-to-day manifestations of bureaucracy, for instance: poor feedback loops, duplicative requests and disproportionate reporting burdens. To truly “bust bureaucracy”, we realised the drivers needed to be addressed.

For me, it’s about reducing the bureaucracy habit. – Registrar

From our stakeholder engagement, we were able to outline the symptoms and drivers of bureaucracy, revealing what we see as the root cause:

We heard that the COVID-19 pandemic had not only stripped away some bureaucracy, it had also reinvigorated those in the system to capitalise on the changes and not let things return to their old ways. We had worried about re-inventing the wheel with this project, but in fact we were continually met with energy and enthusiasm that this is a problem that needs fixing and now is the time to do it.  

Riding that wave of enthusiasm, our report identified the following areas for continued focus and action:

1. Data and information will be requested, shared and used intelligently

2. System and professional regulation will be proportionate and intelligent

3. Day-to-day staff processes will be simple, helpful and effective

4. The government will legislate to make procurement rules more flexible

5. GPs will have more time to focus on clinical work and improving patient care

6. Appraisals will be streamlined and their impact increased

7. There will be greater digitisation of services

8. A supportive culture is needed at a national and local level

What we learned and what comes next in leading change

In the spirit of continued learning and innovation, following the publication we did a team retrospective to discuss what had gone well and what we could improve on in our next project. We identified a few key points to take forward:

• Always think about what you want from interactions while you are designing them to make sure maximum value is achieved. We collected so much information it was vital we put a strict social-research inspired structure around our interviews to tap into key areas;

• Casting a wide net and genuinely listening to others is the best way to create a rich, well-rounded understanding: one person’s bureaucracy is another person’s risk management, you need to hear both sides to understand what can be changed; and

• Leadership is powerful: just because a complex topic has been approached before, doesn’t mean it shouldn’t be approached again. We made sure to look through and capture as much learning and as many recommendations from previous reports that we could – it wasn’t that these were wrong: we needed to understand why they hadn’t been implemented to develop something that would lead change.  

We know that cultural change is extremely hard to achieve, especially through a rapid project delivered by a central government department. The project seeks to encourage long-term cultural change: attention must be kept on the problem and leaders at every level must look at their areas of responsibility. 

It would be nice at a meeting to bring up what is working well… To ask us what’s working well and for ideas for how we could move forward. This is the best time to do a change really, ask us, from the grass roots. – Community Nurse

We therefore view our work as a milestone in a longer-term agenda and so have developed a strategy on how we can ‘bust bureaucracy’ to role-model and drive change. Publishing the strategy was important to highlight action which will make a difference in the short-medium term. Whilst tackling bureaucracy is a never-ending task involving every part of the system, we focussed on change that central government can make in the next few years. It was also an opportunity to showcase the great work that health and care workers have done in the past, including during Covid-19. Although we had gathered lots of evidence of bureaucracy in the system, we also captured examples of innovation and good practice case studies.

Finally, this strategy was important to signal our ambition to the system with specific actions, including setting out the Secretary of State’s goal of reducing unnecessary bureaucracy. We had to practice what we had heard: effective leadership is vital to change a culture. Our publication set the standard that we care about this agenda and will be following up on its implementation as we are doing already with the Secretary of State committing to remove bureaucracy in the COVID-19 vaccine volunteer programme.