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Analysis Quality Improvement

Improving together: collaboration needs to start with regulators

BMJ 2019; 367 doi: (Published 27 November 2019) Cite this as: BMJ 2019;367:l6392
  1. Nicola Burgess, associate professor of operations management,
  2. Graeme Currie, professor of public management,
  3. Bernard Crump, professor of practice in healthcare and leadership,
  4. John Richmond, research fellow,
  5. Mark Johnson, associate professor of operations management
  1. University of Warwick, Warwick Business School, Coventry, UK
  1. Correspondence to: N Burgess Nicola.Burgess{at}

Nicola Burgess and colleagues argue for a move away from top-down regulation to a new approach that facilitates rather than hinders learning across organisations

The regulatory landscape in the UK is changing again. From 1 April 2019 NHS England and NHS Improvement became what is effectively a single organisation with far reaching responsibility for the oversight of the system. The structural features of this change, which will eventually require legislative reform, have been widely debated, not least by those affected by plans for a collaborative approach to improvement in the NHS.12 But there has been less discussion about the style and approach to regulation that might be best suited to drive improvement in the NHS as set out in the long term plan.3 We contend that a major change is required in the way the system interacts with service providers if we are to be successful in developing a new service model for the 21st century.

Currently the NHS relies on positional authority—a hierarchical system in which regulators use their power and leverage to drive change. Drawing on organisational theory we contend that structural change in the regulatory landscape is insufficient to drive interorganisational learning for improvement. Specifically, we argue that regulation needs to shift towards a more relational form of governance in which informal social systems foster learning across organisations. This relational authority emerges through interpersonal relationships characterised by trust and mutual respect and has to be earnt over time.4 To support our argument we draw on our experience analysing a major experiment in delivering service transformation in five NHS hospital trusts in partnership with NHS Improvement and the Virginia Mason Institute in the US (box 1).3

Box 1

NHS-Virginia Mason Institute partnership

In 2015 a five year partnership was established between the NHS and US based Virginia Mason Institute, a non-profit organisation specialising in transforming healthcare. After a competitive tendering process, five NHS trusts were selected to form the partnership and develop localised versions of the Virginia Mason production system.

The production system is an adaptation of that used by the Japanese car manufacturer Toyota. Based on principles commonly known as Lean, the system makes patients central to all activity; any activity that doesn’t add value to the patient is “waste” and should whenever possible, be eliminated.

Although the centrality of patients may seem obvious, many healthcare processes are designed around the needs of the service provider rather than patients. The partnership seeks to build skills in quality improvement within and across the five NHS trusts so that they can redesign processes to ensure the highest quality of care while reducing the cost of delivering the service. Crucially, the partnership shares a goal to support development of a sustainable culture of continuous improvement.


Interorganisational learning

Organisational learning describes the process of assimilation and embedding new knowledge in an organisation underpinned by social interactions between individuals and groups. Cross-organisational networks are becoming more common and offer considerable potential for organisational learning. Like learning within organisations, learning across organisations is facilitated through frequent and structured dialogue underpinned by high levels of trust and information sharing.56 Such reciprocity and trust, however, requires long term commitment from collaborating parties, with regular, meaningful face-to-face interactions.678

Interorganisational learning is best supported by networked forms of governance—that is, when governance is shared between a group of autonomous organisations—rather than by a hierarchical approach. Where accountability is hierarchical, provider organisations are driven to ensure compliance910; by contrast, networked governance motivates autonomous organisations to work together, learn together, and improve together.11

As with interorganisational learning, networked governance is relational, emerging from informal social systems characterised by solidarity among network members, a shared goal, and frequent knowledge exchange.71112 Although NHS policy enshrines the building blocks for more collaborative approaches to improvement through integrated care systems, pervasive top-down regulation may stymie action on the ground. Policy emphasis on managing performance can mean that staff focus on meeting targets, reducing the energy for interorganisational learning.13

How do we build a relational approach to governance?

Moving from top-down regulation to networked governance requires a radical change from mechanisms that rely on positional authority to mandate change, to mechanisms that employ relational authority. The partnership between NHS Improvement and the Virginia Mason Institute shows how a relational approach to governance can be nurtured. The partnership is a five year collaboration to transfer learning from a US hospital with an enviable reputation for patient safety and quality to the English NHS (box 1). Part of this commitment was to establish a transformation guidance board to enable the five participating trusts to support one another, learn together, and foster ongoing dialogue among all partners.

The transformational guidance board is an example of a goal directed, interorganisational network,7 where all network members are working towards a shared goal. Its members comprise chief executives of the five NHS partner trusts, senior members of NHS Improvement, and senior improvement specialists from Virginia Mason. NHS Improvement leads the administration of the network and is an active participant. The board provides two key mechanisms that combine to foster relational authority—a protected relational space and a “compact” (non-binding informal contract14) on expected behaviours and commitments. These mechanisms allow interorganisational learning and network governance to emerge.

Protected relational space

A protected relational space is an area where people can work collaboratively towards establishing new norms and roles that challenge institutional practices.15 All stakeholders are included but individuals must support the aim to change processes; it does not include people motivated to defend the status quo. A protected relational space is crucial for fostering frank and honest dialogue about how to lead change (box 2). All stakeholders must feel psychologically safe to share the challenges they face as well as their successes; this is particularly important when relationships are characterised by a legacy of power imbalance, as in the case between a regulator and provider organisation.

Box 2

What does relational space and relational authority look like?

The most striking feature of the NHS-Virginia Mason partnership is the quality and quantity of time invested in face-to-face meetings. All five chief executives travel to London from various parts of the UK to meet with the same senior executives of NHS Improvement and senior representatives from Virginia Mason every month. The meeting lasts for six hours, during which there are no laptops open, no phone calls taken, and dialogue is fluent, reciprocal, and supportive.

Spending six hours in a windowless room in London with senior representatives of the regulator may sound like punishment, but after more than three years these chief executives told us it was “the best day of the month.” This is because discussions are frank, honest, and reciprocal and there is an air of friendship and friendly rivalry, with an overwhelming sense that all organisational partners are learning together. Relational investments of this nature are uncommon in the NHS; trusts typically compete against each other for business and reputation, and in-person interaction with the regulator is usually a sign a trust is in trouble.

One chief executive explains:

“It’s quite remarkable really … Regulators are usually regulators; they’re usually telling you you’re not doing something very well. But actually, this is different. It’s really important in terms of how you are allowed to create the space to learn and develop, and even when things aren’t going so well, there’s a dialogue to be had. So, it’s a different relationship.”


Create a compact

Moving from positional authority towards relational authority requires a radical change in behaviour. In our example, the first step towards achieving relational authority for interorganisational learning occurred through collective structuring and negotiation of a compact— a process in which the expected behaviours and reciprocal commitments of the regulator and the chief executives are explicitly negotiated and formalised.

Members of the transformational guidance board spent almost 12 months developing the compact. Broad categories of partner responsibilities outlined in the compact include creating the right environment; fostering excellence; listening, communication, and influencing; focus on patients; focus on staff; and a focus on leadership (box 3). In the event that the compact is disrupted—for example, if a chief executive wasn’t sufficiently supported in line with the terms of the compact—a frank and honest discussion takes place about what the board should have done differently.

Box 3

Compact between NHS Improvement and partner trusts

A compact was created to set down the reciprocal commitments of NHS Improvement and the partner trusts in working collaboratively towards their shared vision. The compact states:

“We aspire to fulfil these commitments and will be open to respectful communication from our partner(s) about how well we do in that regard. We accept that this is a developmental journey for all of us.” Some of the responsibilities included are listed below.

NHS Improvement responsibilities

• Behave in a positive, respectful, and consistent way at all levels of interaction with trusts and be open and transparent

• Maintain integrity of positive partnership working even when under external pressure and show empathy with trust issues

• Be candid in offering constructive criticism and receptive in receiving it—always assume good intent

Trust responsibilities

• Act in a way that is respectful, open, and transparent with a commitment to early warning and no surprises

• When under pressure on wider delivery look to the method as part of the solution not a barrier

• Work with the wider system so everyone understands the methods, process, and what is required to maximise benefits


Shifting attitudes

Dialogue is central to interorganisational learning.16 When relationships are hierarchical, interaction commonly veers towards “skilful discussion” designed to keep the relationship with a more powerful actor at arm’s length. A protected relational space allowed our stakeholders to come together regularly, engage in honest reflection, and develop collective thinking towards a shared goal. To our surprise we regularly heard representatives from the regulator claiming they were reflecting on their behaviours as a regulator and how those behaviours inhibit the improvement capability the network seeks to build.

In tandem, the continued commitment of the trust chief executives both within their organisations and to the transformational guidance board is testament to network governance. Chief executives rarely miss a meeting or prepare inadequately. This is partly because of the value that they associate with the meeting and partly because of the social norms firmly embedded across the group. The chief executives all prepare reports of progress and challenges to share at the meetings and they engage in dialogue that supports one another towards improvement goals. For example, one trust showcased its “heat map” of training—a document that visually depicts where trained individuals are located within the organisation. The document can be used to identify concentrations of trained individuals to inform future training plans and improvement efforts. The heat map was deemed an excellent idea and subsequently adopted by the other four trusts.

Can the approach be extended across the NHS?

The role of regulator is changing towards a more facilitative improvement role.17 To date, attempts to transform the NHS have mainly focused on structural change and tightening up regulatory processes that serve to reinforce the positional authority of the regulator. Our analysis suggests that network governance can be more effective at fostering collaboration for improvement, and that such governance occurs through development of relational authority. We acknowledge that the partnership represents just one example of a networked governance approach and this particular example is limited to a collaboration with just five NHS provider organisations. The challenge will be how to replicate this approach across the broader system.

To reiterate our earlier contention, relational authority is earned over time. We have identified a safe relational space and the process of creating a new compact as important conditions to bring about interorganisational learning and network governance. A different approach to governance is plausible, possible, and desirable.

Key messages

  • If collaboration between organisations is to drive improvement, regulators need to reconsider their approach to the exercise of power and authority

  • Top-down governance forces organisations to seek rapid short term solutions that do not address complex problems

  • Effective collaboration requires investment in developing relationships between organisations characterised by trust and reciprocity

  • A relational approach between the regulator and service providers can foster interorganisational learning and governance


  • Contributors and sources: The authors are engaged in a formative and summative evaluation of the NHS-Virginia Mason partnership. The evaluation uses mixed methods, but this article is based on the qualitative elements. The methods included over 50 hours of observation generating over 600 pages of detailed notes and verbatim transcription; 14 semistructured interviews with members of the board and analysis of the detailed minutes of all board meetings since its inception in October 2015. NB was responsible for the planning, conduct, and reporting of the work described and for writing the article. GC and BC provided support in the planning, conduct, and reporting of the work and the revision of the article. JR provided a supporting role in the conduct of the work, including interviews and observations, and MJ supported the planning. NB is guarantor.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • This article is one of a series commissioned by The BMJ based on ideas generated by a joint editorial group with members from the Health Foundation and The BMJ, including a patient/carer. The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees and The BMJ’s quality improvement editor post are funded by the Health Foundation.

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