Public Sector Failure and Resilience: Lessons for Healthcare Policy

Introduction: Since the publication of the Francis Report into the failings in care at Mid Staffordshire NHS Foundation Trust and the Berwick Review into patient safety, Trust leadership has needed to embrace the problem of delivering more efficient, effective and integrated care whilst balancing finances and fostering “an inquisitive, curious and hungry learning culture” to improve the delivery of patient care. In response to the Policy challenge fund, the team at University of Leicester and Cardiff University examined failure and resilience in other sectors to inform healthcare leadership and policy. With the aim to build interest and expertise in rapid policy analysis within the academic and policy communities, and generate insight that will support high quality decision making and improve the quality of the policy debate. Other public-sector organisations, such as the police, prisons and schools, which have faced comparable challenging circumstances, are exemplars of how to achieve positive outcomes. The research examines these once failing or poorly performing organisations’ journey to recovery, to identify the key strategic themes and actions that are relevant for healthcare policy and practice. Research Context and Methodology: The cross-sector research is underpinned by the theory of organisational resilience: “the ability to anticipate, prepare for, respond and adapt to events – both sudden shocks and gradual change. That means being adaptable, competitive, agile and robust”. Organisational resilience can be explained by its conceptual components: Engineering resistance, Ecological resistance and Adaptive Capacity (‘EEA’). Having been observed previously in the biological environment, these elements have been applied to psychological system. This cross-sector study applied the EEA approach to examine responses to failure, resilience and recovery. To further understand public sector failure and resilience systematic search of the grey and academic literature was conducted. Six in-depth case studies were conducted in the Criminal Justice System (CJS) and Education sectors. These were purposefully selected by examining key inspection reports, to identify organisations that had gone from ‘poor’ performers through a rapid trajectory to ‘good’ or ‘outstanding’ performers on the subsequent inspection. The case studies comprised two police, one prison, a youth justice service and two secondary schools. Case studies involved conducting semi-structured interviews with key personnel involved in the improvement journey in these organisations, and an analysis of inspection reports and other key documents. The EEA resilience framework was applied to interview transcripts and documents to identify key themes, actions and activities that supported the organisational turnaround. Summary Findings: The evidence from the interviews supported the manifestation of the three theoretical components: engineering resilience, ecological resilience and adaptive capacity. These three elements were further conceptualised into four quadrants of a systems framework (1) service users/individuals, (2) groups/teams, (3) organisational and (4) policy. Strategic planning and action taken by recovering organisations evidently spanned these four perspectives; some actions interacted and integrated across the three elements and/or quadrants. For example, ‘community involvement’ had an impact on building engineering resilience and adaptive capacity at an individual level; whereas ‘sharing challenges with third party organisations’ was instrumental at policy level in respect of adaptive capacity but at team level in building ecological resilience. Observations: Engineering resilience is described as the capacity to rebound to an original state after difficulties; the route to this was noted to require substantial changes in some cases, such as restructuring and/or replacing of the leadership team/team-members. The forging of stronger or new relationships with other bodies was the focus required to enhance ecological resilience; similarly, new or improved relationships provided peer and external reviews. These in turn provided a catalyst for the revision of processes and practices, one aspect of developing ecological resilience. Such expanded perspectives also provided a contribution towards the improvement in adaptive capacity, by increasing the organisations external communications, plus communication with other stakeholders and from the top-down and bottom-up internally. Conclusions: A multi-faceted approach can provide an effective strategic solution for nurturing recovery based on the elements of organisational resilience theory. Outcomes are dependent on diverse enablers that include both human efforts and technological solutions. The keystones to positive results, turning around failing organisations and building resilience in preparation for future challenges, include a readiness to adapt to an outward looking emphasis and the embracing of critical feedback to inform long-term strategies. The report ends with recommendations for health and other public-sector leaders with an interest in developing organisational resilience and facilitating rapid recovery from failure. Whilst the research team recognise that further research and development of the Engineering resistance, Ecological resistance and Adaptive Capacity (‘EEA’) model is needed to establish stronger validity it still provides a useful framework and reflective tool for strategizing responses to failure.