As the NHS undergoes its latest round of reform, what shape will the new NHS look like? Piecing together the evidence the new design of the NHS seems to be coming into view. I’ve call it the Layered Tree Model. What is it? How might it work? What might its weaknesses be? And what on earth does the Cynefin Framework have to do with it?
Table of Contents
Why Does the Shape of an Organisation Matter?
Whenever an organisation is reformed, those that reform it usually have an ideal shape in mind. This is the rationalist view of change. Where the problems of an organisation are related to it’s shape. Sometimes that is true. The shape of an organisation will often determine what it does well and badly. Some organisations are designed to be flat structures responsive to the needs of customers, whilst others have a strong hierarchy responsive to the needs of leaders, others have control centeralised and others distributed. As well as everything in between.
Understanding the intended shape of an organisation helps us to prepare for and implement the change, as well as understand what the opportunities and challenges are.
The Emerging Shape of the NHS
What is the planned shape for the new NHS? How are the upcoming reforms intended to reshape it to fix the ‘broken NHS’? A new shape of the NHS appears to be emerging from the documents that have come out so far. I’ve called this model the ‘Layered Tree’ Model of the NHS. The tree describes the new clearer lines of finance and responsibility. It seems to be based on around 3 distinct layers: financial, clinical, and community, each playing a distinct role.
The Current Structure of the NHS
The current structure of the NHS is hard to describe and understand. To be honest, there doesn’t seem to be many people that do. At the moment the NHS is a messy web of interconnected organisations, all with different functions and roles. From diagnostic hubs to cancer alliances and health innovation networks (formally AHSNs). But also providers of rehab services, mental health providers community health teams, social care partners, and voluntary sector organisations, all working alongside, Integrated Care Boards (ICBs), Integrated Care Systems (ICSs) Primary Care Networks (PCNs), and acute hospital trusts.
The Need For Reshaping the NHS.
This can make it difficult for staff, patients, and even system leaders to navigate, coordinate, and make sense of who is responsible for what, and how services are supposed to connect. It is probably not surprising that this messy structure of the NHS is one of the reasons why senior leaders think the NHS is broken and needs reforming. After all how you can optimise or control something you don’t understand?
The NHS Tree Structure
The branching tree structure of the future NHS depicts how those running the NHS view the flow of power resources and accountability through the hierarchy of the NHS. This is very much a top down restructure of the NHS at this stage, no matter what is said. (As demonstrated by government decisions to abolish NHS England and make significant cuts to ICBs.) That matters, as the intended new structure will be to move towards an idealised design.
Clear Branches of Control
This tree reflects the lines of control that the government want to use to make the NHS responsive to their needs. The branch structure creates clear lines of accountability. They will be keen to reduce overlap and uncertainty about roles and responsibilities if they follow through on their quest for control and accountability.
The changes signal an end to the reorganisation of the NHS brought by Andrew Lansley’s reforms in 2012, which “created burdensome layers of bureaucracy without any clear lines of accountability,” said the government this week.
(BMJ)
The Simplification of The Tree
In the minds of senior leaders, we are working towards simplifying the NHS to move as close to this ‘Tree of Accountability’ as possible. Whilst this certainly does not capture the complicated network of organisations that currently makes up the NHS. There is a clear process of rationalisation of these organisations in progress. With organisations that don’t fit under pressure. It has also been discussed that providers are expected to work towards being Accountable Care Organisations in future: Merging and integrating much of the local networks of the NHS. Bringing this web of organisations into a clear line of control and responsibility.
Primary Care and the Lines of Accountability
The controversial part of this model is primary care and whether and where they are part of the lines of accountability through Secondary Trusts or Accountable Care Organisations or somewhere else. It is important to say this has NOT been announced. It may be that this is for local systems to decide. But there is very much an open question if the responsibility for oversight of primary care is taken from ICBs as they are refocused on ‘strategic commissioning’. That leaves the responsibility for primary care a very open question. (To be clear I’m not advocating for this change, only pointing out that this seems to be a likely direction of travel based on current information).
The Tree of Flexibility and the NHS
A tree seemed apt not only the structure, but the flexibility of the intended system. As we move up through the tree there is likely to be a level of increased variability between areas. With the core being very stable and inflexible, the providers having limited flexibility and community focused work is much more adapted and tailored to the needs of local communities.
The 3 layers of the NHS
There are 3 layers of the NHS that seem to be coming into view:
( alluded to in this letter from new NHS Chief Executive Sir James Mackey)
- A financial and highly structured core. Enforcing “a rules based system”
- A clinical layer – responsible for delivering expert led clinical treatment.
- A community layer – integrating care and health management in our communities. (As described by the Neighbourhood Health Guidelines)
Let’s dig a bit deeper into each layer and get a better understanding. Curiously, either by accident or design these 3 layers align well with the Cynefin Framework (at least in part), as we shall explore. (
Layer One: The Financial Core – Stability and Standardisation
At the base of this tree sits the financial layer: the centralised, directive core of the NHS. Much like a tree’s trunk, this part is solid and largely inflexible. It is the highly constrained part of the NHS. It has been said that it will run “a rules based system.” So it is designed to be clear and unambiguous. On taking up the role Sir Jim Mackay has repeated mentioned the importance of transparency.
Purpose and Function of Layer One
The purpose and function of this core structure to provide the infrastructure, budgets, contracts, and procurement pathways for equipment, and medication and allocate funding levels throughout the system controlling the flow of resources through the NHS.
Integrated Care Boards Changing Function
Crucially, this layer is also being extended to local areas. Integrated Care Boards (ICBs), originally designed as locally integrating structures, coordinating the delivery of local care are shifting into a more directive role. Rather than leading local strategy, they will most likely expected to as regional agents of the national financial and rules based system, focused on contract management and delivering targets and strategic commissioning.
Finance Sets The Standards
In this financial layer, there is a strong emphasis on defining standards: quality controls, contracts and rules, and best practices in this layer. Making violations and variations something that won’t be tolerated. Whilst this part of the system, especially the financial, prioritises predictability. An important function of this layer is regulating and attempting to control the rest of the system through setting financial standards and policing the rest of the system through a set of rules. We don’t yet know how the rules will be policed but punishment for rule breaking is inevitable for such a system to function.
Marginalisation of Clinical Leadership
A core part of the role of NHS England and ICBs has been to provide clinical leadership. However, the newly defined organisations look like they don’t include clinical leadership as a core function. It may not be total, but with the core stated focus on being finances contracts and rules it is hard to know what real role clinicians are expected to play, beyond a limited advisory role. There seems to be a belief that clinicians’ job is best focused on delivering care. As evidenced by the recent push to reduce corporate nursing roles. Such changes are drivers of this stratification of the system.
Layer Two: The Prover/Clinical Layer – Expertise and Specialism
The second layer of the tree is focused on clinical care. Branching out from the trunk are the large branches. These are the providers; secondary care hospitals, mental health trusts, diagnostic hubs, and other changes such as GP practices performing minor surgeries. This is the layer of expertise.
The Layer of Expertise Is A More Complicated Layer
In contrast to the clear simple rules of layer one, here, things are more complicated. Clinical experts make nuanced, evidence informed decisions about diagnostics, interventions, and population health management. It’s about navigating trade offs and learning from research and experience. It is about creating and following guidelines: rules that are to be followed but can be negated, if and when there is good reason. (e.g a patient may be too frail for a procedure)
Data Led Services
Decisions are expected to be based on statistics and be data led. So a high throughput of patients is required. Care may be personalised, but it is not personal. Adapted to individuals when evidence suggests. Rather than focusing on building services around patients, patients are fitted into the system as much as possible. There is a strong emphasis on efficiency productivity and flow in this level.
This is also a level of coordination between experts. Where expert led services are expected to share learning and good practice. These services are expected to work alongside each other. There is some flexibility in this layer. But it needs to be explained evidenced and justified.
A Place of Tension.
Stratified Systems Theory, by Elliot Jacques tells us that this is likely to a place of tension. Where financial demands conflict with clinical needs. Many large providers already have a gap between management and clinical teams, which can be a source of conflict. For organisations to be successful they will need to build relationships and trust to reconcile those tensions and work together to balance the needs of stakeholder to close that gap.
Layer Three: The Community Layer – Relationships and Adaptability
The community layer is at the top of the tree, the leafy edges of our healthcare system, where community services grow. This includes everything from district nursing to social prescribing, physio to pharmacy, and, eventually, Neighbourhood Health Services driven by place-based partnerships. This is where people first present their problems. And where the system is most flexible.
The Complexity of Community Healthcare
This layer is complex. Interactions are messy, social, and unpredictable. Professionals here are dealing with long-term conditions, inequality, social isolation, housing, trauma, disabilities mental health conditions, prejudice, addictions, and social isolation, as well as the natural variation of people and communities. Often all at once. There is a blurring of the lines between social issues and health.
GP Centred Community Work?
The core concept of the Neighbourhood Health Service, according to the guidelines, is to centre this community health service around GP practices. But this creates a real conflict and challenge for the already overwhelmed GPs. They are torn between on the one hand expert clinicians and on the other hand being community leaders engaging people and providing wider social care. Of course, some will take the challenge with relish, but many may struggle with this dual role. Taking on the expert problems of health as well as the wicked problems of society is a very big ask.
Community Health Is An Emergent Layer
It is important to say that this layer of the NHS is very much underdeveloped at the moment. Whilst there are some successful pilots such as the Washwood Heath Service in Birmingham. This is not a new idea and the NHS has repeatedly failed to implement such ideas sustainably in the past and never managed to implement them at scale. (Read my guide to the opportunities and challenges in implementing the Neighbourhood Health Service Here)
Communities Require A Different Model of Healthcare.
Our health systems are not designed for community health. Our healthcare system is designed around a model of healthcare interventions being temporary interventions to fix people or long term applications of drugs. It is quite likely that the NHS may have to choose between implementing community work well, or sticking to its principles and failing to implement effectively.
If it continues to rely heavily on drugs for management and prevention of poor health the costs are likely to sky rocket, as more and more at risk groups are found. Whilst our healthcare system is designed for standardised models the smaller the service the more likely that it needs to be varied to fit, it’s environment. (e.g. a service based in a wealthy suburb vs an old industrial centre)
Communities As Nurseries For Innovation.
This is also where the greatest potential for NHS innovation lies. It’s where test-and-learn approaches can be trialed without destabilising the whole system. It’s the part of the NHS that most closely partners with local authorities, businesses, and citizens to tackle the real, wicked problems. Communities can be and probably need to be learning spaces bringing people together to spread good health throughout our society.
(If you would like to learn how to run community projects please read this guide)
A Model Rooted in Complexity
What we’re seeing emerge in NHS reform is a stratification of the different functions of the NHS. By accident or design this stratification at least as conceived maps neatly onto the Cynefin framework:
- The Financial Core Layer = the clear domain
- The Clinical Layer = the complicated domain
- The Community Layer= the complex domain
What is the Cynefin Framework
Dave Snowden’s Cynefin Framework helps people make decisions by categorising situations into five domains:
- Clear (or Obvious/Simple) – Situations where solutions are well-known.
Action: Sense → Categorise → Respond (Best practices). - Complicated – Situations that require expert analysis because answers aren’t immediately clear.
Action: Sense → Analyse → Respond (Good practices). - Complex – Situations where outcomes can’t be predicted, needing experimentation to find answers.
Action: Probe → Sense → Respond (Emergent practices). - Chaotic – Situations needing urgent action to stabilise quickly.
Action: Act → Sense → Respond (Novel practices). - Disorder – Situations where it’s unclear which domain applies, leading to confusion.
Action: Clarify and move into one of the other domains quickly.
The framework guides you to understand which situation and environment you’re in so you can respond effectively. If you would like to understand more please read my guide here:
Why is this Helpful?
The Cynefin Framework is more than just a typology labelling the domains. It tells us how best to act effectively in each of these domains.
Different Leadership Styles For Effect
The key to using the Cynefin Framework enables us to understand the leadership style that might be most effective in your situation. My model is a just a guide of the dominant decision making in each layer, as described by NHS England. In reality it is important to understand the situation and nature of the problem and tailor your response regardless of the part of the system you are in. eg. Not every decision in the expert layer is expert led. Whilst community and financial layers will also benefit from expert decisions on a particular subject
Why This Layering May Be Accidental?
I’ve not seen anything to suggest that this stratification along the lines of some of the domains of the Cynefin Frameworks is anything other than unintended. This model may be purely evolved by accident. This model might have been developed through feedback loops of the existing system amplifying the core characteristics and the level of flexibility that each layer required at each level.
Feedback Loops and Attractors
The model may have emerged based on feedback loops based on 3 distinct attractors. The first attractor is one of financial stability, the second around high quality clinical care and the third around socially connected communities. Rather than balance out the competing demands and visions for the NHS, it looks like planners are trying to create 3 local optimums with relatively loose connections between each. Here is a more detailed look at the 3 attractors:
1. Leaders and Finance Attracted to Clarity and Certainty.
The attractor for people at the top of the NHS is order and predictability. The people at the top of the NHS (or the bottom in this particular model -purely because the tree didnt make sense otherwise) are finance people and bureaucrats at the top of the system want a simplified rational system they can understand. They don’t want things complicated or complex as they want to know what is happening and that when something needs doing they have the power to do it.
The level of information crowding in at this level can produce a cognitive overload very easily. Noone can possibly get their head around every clinical discipline in every part of the country and all the vagaries of the system. So those with clear simple approaches have the loudest voice. So they are deliberately exporting the greater complexity to the layers below them to maintain their clarity.
2. Providers Are Attracted to Providing Excellent Care
The attractor here is for clinical excellence. The clinical layer in the middle of this system consists of the work predominantly of Drs nurses and all kinds of specialists. They don’t have the luxury of the simplistic approach of the bureaucrats. The expertise at this level is the hard won knowledge over generations of diagnosing and treating large numbers of people. It is predominantly aggregated knowledge. They are focused on good practice. What is the right thing to do most of the time, or when further judgment is needed. The upshot is that experts thrive in this layer. Their worlds are too complex for the bureaucrats and finance people at the top. So they become the predominant voice of this layer.
3. Communities Are Attracted to Social Connections
In terms of community the social elements are the big attractor. It is a complex area for the NHS that it has very little understanding of. (Not least because its capabilities in this area have much diminished from the days when the GP was a central hub of the community). Community services are represented not by an elite cadre of experts, but by a plethora of voices all demanding different things. Successful action often requires coordination between a number of actors, rather than through a single expert. Their needs are often unique. (Black of African origin are NOT all the same despite what NHS tickboxes suggest).
Taking this into account it is easy to see just by the feedback loop of consulting with people at these levels, that the NHS reforms may have evolved into something very akin to the 3 domains in Cynefin (with confusion and chaos obviously underrepresented.) What is interesting though is the intention to optimise different types of system at different levels.
Where Does Technology Sit?
One area that we don’t know about in the reforms is where technological change and innovation are best sitting. I would argue technology has a different role in all 3 areas.
On the one hand, if we want a data system with single standards that work everywhere, clearly this needs to be done from the core. But if we want expert implementations aligned with clinical pathways then this should be done at the provider level. Where technology can be used to assist in reducing waiting lists and productivity and optimise the flow and performance of the traditional clinical pathways.
However, there is also a major application for the technology in the community helping prevent and manage long term conditions through more personalised AI and other technology. AI can be used to help connect people together in new ways. Interestingly tech in this area will be commodified, so it favours ‘off the shelf’ commoditised solutions. At the same time because of the dynamic complex nature of community, a host of new solutions can be trailed and tested in this layer. Focused on meeting the needs of particular groups communities or localities.
Where The New NHS Structure May Fail According to Cynefin
Each area has it’s own strengths but also weaknesses. The most obvious failure point is the financial layer. It has neither the flexibility nor understanding to cope well with expert decisions (E.g. clinical tradeoffs) or the complexity of demand. Ashby’s law of requisite variety needs to be met by this level just like any other organisation. So this layer is likely to struggle with complexity and tensions if it is operating in a rules based process. Particularly when unplanned situations requiring cross-system coordination occur, (such as pandemics and mass casualty incidents)
Other Threats to This System.
The financial level can also fail by imposing its worldview on other parts of the system. Enforcing inappropriate levels of simplicity on providers. Whilst there are steps put not try and limit this we know that bureaucracies and financial leaders ALWAYS try to overreach themselves (we could argue how much of the problems our society faces now are because of this.)
Providers could struggle caught between the simplicity of the financial system and the complexity of demand from communities.
The biggest threat to the community model is both over simplistic controls from the centre as well as the leadership by experts who despite their best intentions may try and impose too much order and control on the emergent challenges of communities. At the same time the clinical expertise may find itself considerably diluted in the community layer.
Reform Requires Systemic Thinking, Not Just Structural Change
There’s a long history of NHS reform plans failing; not because they lack ambition, but because they impose top down structures on bottom up realities. Frontline services are a patchwork of workarounds, ad hoc solutions and practices learned from colleagues and years of experience. It’s hard to change these realities to a new ‘To be’ future. So even if this is the intended structure the reality may prove to be different in implementation.
But if followed in this way it would be helpful to understand the strengths of weaknesses of each part of the system:
If we recognise that each layer of the NHS serves a different function, and respect the environment of each, we can build a more adaptive, inclusive system. A system where:
- Finance provides stability, not control
- Clinicians are free to lead the provision of medical care
- Communities are empowered to create local solutions adapted to their needs.
This May Not Be The Best Structure of the NHS
I’m also not saying this is how the NHS SHOULD be organised. Only that this seems to be the current intention. The real goal of this article is to help people be aware of and make sense of the changes. It is not to portray that every decision a provider makes should only be done by clinicians nor that every decision of the core team is and should be simple. It can be seen as a map to help us orient ourselves to what’s going on and what the future of the NHS might look like. But the map is not the territory, and what really matters when making decisions is understanding the situation you are in.
An NHS Structure That is Best Adapted To It’s Environment
We do need a sense of direction of what a better NHS looks like, but we don’t need another rigid plan. We need a health system that functions and makes appropriate decisions for the circumstances. The most important thing the NHS should do as it makes changes is to learn at every step, adapting to meet the needs of the world and building capability to respond to an ever changing world. Seeing change as a journey, not a destination.
A System Needs Complexity To Survive.
That means embracing complexity, not fighting it. It means investing in relationships, local leadership, and learning systems that span all three layers.he system as a whole needs to be responsive to all the challenges put upon it to flourish (Ashby’s Law of Requisite Variety.)
Healthcare is a System Not Parts To Be Optimised.
It is important to remember that healthcare acts as a single system. You can’t fix it by optimising each part separately. What matters most of all is how those parts interact together to produce the best possible care for all the patients. The real test of changes is the experience and outcomes of staff and patients. This is what we should be monitoring at every stage to make sure our changes our ‘healthy’. When implementing any change we need to respect the plans and understand what they are trying to do, but at the same only make changes that are rooted in creating a better healthier reality for our society.
Conclusion
The reforms NHS appears to moving towards a structured ‘Layered Tree’ model: financial stability at its core, clinical expertise as its branches, and community adaptability as its flourishing leaves. This aligns, perhaps unintentionally, with the Cynefin framework, offering valuable insights into how each NHS layer should operate and respond. While this layered approach promises clarity and targeted leadership, it also carries inherent tensions. Its success will hinge on embracing complexity, fostering open communication between layers, and cultivating a learning-oriented health system that continually adapts to the real-world experiences of staff and patients. Only by balancing stability with flexibility, expertise with community insight, can the NHS truly thrive at every level.
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