Scale, Openness and Value

  |   Thought Leadership

Viewing a lot of NHS strategy making from the outside and the recent development of hospitals looking to merge or federate with other providers or with primary care. How many times have you seen or heard the words “operating at scale”.

At this moment, scale in the NHS appears to be more about consolidation.

Consolidation can bring greater integration and control as well as the opportunity for capturing scale efficiencies. However, the significant investment in vertical infrastructure and organisational dynamics, combined with market concentration, often bring challenges in capturing those opportunities and delivering them to patients and service users.

A key element for health & care systems now is to work out the context for where value is created. The reasons why large firms had leverage in the past-economies of scale and information efficiency have changed. Since 2000, there has been a dramatic decrease in the costs of communication; changing one of the fundamental reasons that centralised scale creates strength. This change now allows us to see scale in an entirely different way through and with connected individuals, groups or organisations.

Within a more industrialised mind-set organisations become more powerful or stable by being bigger. But in today’s world, organisations become more powerful by working with others.

Look at it like this. The industrial era honoured the institution as a construct of creating value. Today, more successful companies honour value creation starting with the single unit of a connected human.


Achieving scale in the NHS is more likely to happen through creating openness not consolidating organisational form. Openness is more than “open source”. The value created by platforms that enable people to contribute can surpass the value created by organisations trying to control each piece.

Example 1 – Devolution

Any devolution city has an excellent opportunity to deliver at scale. At this moment, Devo seems to be focusing on organisational form, consolidation and consultation. But what if a city did something that reflected a belief that scale could be achieved through its communities and not just from organisational size.

What if Devo stopped all management effort relating to organisational form, structure, budget setting and management of efficiency?

What would happen if a city focused all its effort on creating public sector transparency with its citizens and allowed all public sector data to be published with the purpose of improving public services and local accountability?

The Devo project could become one famous for aligned purpose, community and openness. Instead of being industrial, keeping everyone out to maintain a turf, the Devo project can find ways of bringing connected people and organisations together.

Example 2 – ACO

Nowhere is it better to see the conflict of historical strategic thinking and the present than the creation of NHS ACOs. A focus on form, to create accountable care between organisations misses the point completely. That is to develop a different relationship between each other (sure); but more importantly provide openness and transparency to the citizens that an accountable system serves. That way channel shifts may actually happen.

Again, what if partners in talks about an ACO suddenly stopped working on organisational form, structure, ownership and budgets. And they focused exclusively on openness and transparency of information?


Openness offers something. It allows for many and more contributions to create a bigger outcome.

At a societal level, it allows for a shift from what is to what will be, so that many voices can participate in solving old problems and perhaps invent the future. Banking on openness is akin to saying you have hope in people to create.