Mergers take a long time. That includes NHS mergers, which can be disruptive and controversial, often challenge culture and always stretch organisational capacity. Add to that the regulatory assurance processes in the NHS, which have thankfully been simplified in recent years, and they can become large, long-term projects. Matt Custance, however, thinks the process should be even longer.
"Even longer?!?" I hear you splutter, but let me explain. We’re definitely not suggesting any more regulation, hurdles or assurance. Or that time frames should slip. We strongly support recent efforts to streamline and reduce these processes. Instead, we are saying that a truly successful transaction programme starts sooner than people might think; even before the strategic case is created, and carries on way beyond the transaction date into the implementation phase.
Two issues for NHS mergers
Part of launching our expanded NHS advisory business has been comparing the M&A experience of our newer team members with those who have been with the firm for years. Across our conversations, two issues were raised again and again:
- Was the merger really the right option in the first place?
- Did the merger deliver on the initial plans?
Maybe the benefits weren’t pushed through or the integration wasn’t completed. It’s easy to allow the pressure of day-to-day delivery to overwhelm the transition and integration challenge. In some cases, the merger seemed to be more or less abandoned. In other words, the M&A process seems to have the most problems at the beginning and at the end.
“Start at the very beginning, it’s a very good place to start”
Sometimes the reasons given for NHS mergers aren’t actually particularly good in themselves. People often quote:
- size or scale
- a system expectation
- performance failures in one or both trusts
But what you really need to know is how specifically the merger partner is going to add value. Ask:
- What will the merger unlock?
- Do they allow scale in sub-scale specialities?
- Do they bring management excellence?
- Could the merger fast-track co-operation that might deliver clinical or research excellence?
- Do you actually know where your trust needs help?
So, to start with, you need a realistic view of your forecast clinical, operational and financial performance, alongside your challenges and opportunities. Easy right? But often there isn’t a shared view, even within trust senior management, let alone across the local or regional health system, where support can be vital!.
If everyone is on the same page about how you're performing and what your barriers to excellence are, it’s going to be easier to work out a plan. It's easier to be clear about whether that plan needs the close co-operation of one of your neighbours that a merger can bring when everyone agrees. And, of course, it goes without saying that merger candidates need to be similarly clear on their own position and see the rationale for their involvement too.
Plans for NHS mergers should be worth more than the paper it's written on…
The NHS mergers process is long and often draining. It’s no surprise that, once Day Zero has passed, there is a tendency to relax. The focus comes off the merger process and day to day pressures, which may have been ignored during the rush to complete, take on a renewed importance. It’s understandable to slow down, but unfortunately, that’s not good enough. The first couple of years is when you are finally free to bring things together; to collaborate with no organisational boundaries in the way. This is when you can deliver what you set out to do and when you can make a difference directly.
- conscientiously tracking performance against the integration plan
- maintaining momentum, delivering changes as soon as safely possible and celebrating the benefits to build enthusiasm for the change
To begin with, the focus will be about getting everyone familiar with the merged Trust’s systems and processes. You will also want to get your priority service changes done. These are likely going to be about dealing with fragile services at one or more sites, and they could be quick wins, but the work doesn’t stop there.
Systems, space and kit
To deliver the merger benefits, you are probably going to need the right systems and digital solutions in place, as well as the right facilities and equipment available. All of this takes time and often money to deliver and will set the pace for the other changes. It therefore needs to be a priority in both the run up to Day Zero and the following years.
Using the time wisely
Every service should already know its role in delivering the initial integration plan. But that doesn’t mean blindly implementing that plan and stopping there. Just as the best organisations encourage everyone constantly to look out for ways to improve, we should be encouraging all our services to discover the best ways to come together. As people start working more closely, are they finding new and better ways to collaborate? Maybe opportunities emerge even in services you thought would be business-as-usual.
Doing it all well
If the business is to own the changes being made, it needs to lead those changes. But service leaders and managers only have so much capacity. This is the constant juggling act that major change in the NHS always faces. One way or another, the Trust is going to need additional resource to deliver the integration plan, just as it did during the business case development process. Managers will need support to press on with the integration challenge and the board needs to stay informed about progress, with benefits tracked and people held to account.
So, Trust leadership needs to find and protect resource for the implementation challenge; leadership needs to provide the delegated authority to make the changes happen; managers will need the right support for change management, HR, digital, facilities and integration, and programme management, if they are to deliver the true potential offered by the transaction.
NHS mergers: conclusion
A lot of work has been done collating lessons learned from NHS mergers and beyond. Two repeating themes are the need to get the analysis and rationale right upfront, and not to skimp on the integration task post-completion. Our key suggestion, therefore, is that NHS mergers is one complete change process and that getting the beginning and end of that process right will greatly increase the chances of success. Of course, all of this assumes that a merger does end up being the right answer for you and whether that is true is another question entirely!