Seven lessons for the NHS: focus on transformation and efficiency

What can be learnt from Transport for London?

The NHS faces a complex combination of challenges: NHS providers are expected to restore financial balance by 2020/21 and transform services to meet the changing of needs of the population, whilst maintaining, if not improving, the quality of care for patients. While part of the challenge has been met through budgetary increases and transformational funding, the vast majority will need to be addressed through increased efficiency and new ways of working.

Transport for London (TfL) made an interesting case study as it faces very similar challenges to the NHS: growing demand for services coupled with rising customer expectations, a requirement to invest significantly in upgrading and modernising its infrastructure whilst also improving the efficiency of its operating model, all in the context of an organisation that until recently had gone through limited major change.

TfL transformed its services through its ‘Fit for the Future’¹ programme and as a result customer satisfaction levels are at a record high, the cost of services has reduced by nearly a fifth and the efficiency of the transport network has improved through the implementation of a new operating model enabled by technology.

Despite obvious differences in the objectives and services of both organisations, TfL offers some compelling lessons to the NHS on how to successfully drive up efficiency whilst simultaneously delivering transformational change.

We explored what learning can be taken from the TfL experience and applied to the NHS by bringing together leaders from both organisations in roundtables. Seven lessons emerged from discussions, which provide food for thought for leaders tackling similar challenges in the NHS.

Seven key lessons for the NHS

Seven key lessons were identified from TfL’s experience of undertaking large scale transformation whilst also making efficiencies. Below we consider their application to the NHS and the practical steps NHS leaders could take to put them into action.

1. Transform services around customers

TfL’s experience: Delivering a world class customer experience has been central to TfL’s transformation programme. They put their customers at the heart of their business and transformed services around them. Key to this change has been a radical workforce transformation, which involved moving staff from underused ticket offices and back areas to public parts of the station. To enable change, TfL invested heavily in a people change programme, including developing a comprehensive customer-focused programme of learning, creating a new customer service supervisor and manager roles and flattening the hierarchy so that managers are closer to customers and front line teams. As a result customer satisfaction levels are at an all-time high.

How it applies to the NHS: Sometimes the circumstances in which patients and care givers interact mean that patient experience can fall down the rung of priorities. The “hello my name is…” campaign aims to improve patient experience by getting the basics of communication right. Over 100 NHS organisations have now signed up to the campaign, but more could be done to develop a more customer service style model of care delivery.

Action the NHS could take: As well as actions around training and development activities, which are of course an important factor in reshaping the workforce, NHS leaders will also want to consider how they maintain new behaviours. Thought should be given to how positive behaviours are incentivised and negative behaviours performance managed, with a clear link between performance and reward.

2. Use technology as an enabler

TfL’s experience: Technology was a key enabler to TfL’s workforce transformation and its shift in operating model. For example, TfL recognised that customers with smartphones were often better informed than station staff. Staff are now equipped with the latest mobile technology so they can access information quickly to help customers on the move. Contactless payment means customers no longer have to queue to top up their Oyster card or buy a ticket they can pay using only a bank card across the transport network and Wi-Fi is now available at 150 stations.

How it applies to the NHS: The Integrated Digital Care Fund, which made £240m worth of capital funding available to NHS organisations to implement initiatives that capture and link clinical and care information, provides an opportunity to exploit digital technology to create a more efficient and responsive system for patients. If NHS organisations want to put individuals in charge of their own care they should prioritise putting in place interoperable systems and a single patient record, which would allow patients to interact with services across the system.

Action the NHS could take: A key piece of learning from TfL for NHS leaders is that they need to invest at least as much in programmes of organisational change as they do in the technology itself. If the benefits of new technology are to be realised, it is critical that staff are trained in how to use it before it is introduced and receive ongoing support to maximise its potential. Engaging staff early on, including in the design and development, as well as implementation stages and then identifying “change champions”, particularly clinical ones, is important. 

3. Standardise to improve the quality of care

TfL’s experience: TfL has standardised its access points (i.e. stations) across the tube network. There are four types of station, each with a standard definition and operating model. This has helped TfL to provide a more consistent service across the Underground.

How it applies to the NHS: It is well documented that many people struggle to navigate the urgent and emergency care system and this often leads to avoidable trips to A&E and general practice. The NHS has launched numerous public awareness campaigns advising people which services to use based on their needs, though success has been difficult to measure.

Action the NHS could take: Acknowledging that standardising tube stations in London is very different to standardising healthcare, there are still opportunities where standardisation could benefit the NHS. For example, establishing clear access points that are standardised across localities could prove beneficial. Standardisation enables easier communication and simplification for patients trying to navigate the system. Hospital chains could also be used to drive up the quality and consistency of care by implementing standard operating procedures to smooth out variation. 

4. Integrate planning and delivery of services

TfL’s experience: TfL took a holistic, strategic approach to improving its stations. It realised that a total organisational transformation was required, rather than a piecemeal approach that attempted to resolve its issues on a station-by-station basis.

How it applies to the NHS: It has been widely acknowledged that individual organisations cannot hope to solve the challenges of their overall populations. A population-based approach to health is viewed as the “big ticket” for new models of care. However, the potential role of the private sector in developing partnership models to support the NHS should not be underestimated.

Action the NHS could take: Engaging with other health systems and establishing improvement techniques from other industries such as 'Lean' and 'Six Sigma' are happening in pockets, but the breadth and pace of these need to increase to exact rapid change.

5. Give management time and support to make changes

TfL’s experience: Like the NHS TfL went through a number of CEOs some of whom were more bought into the transformation than others. Given the churn in senior leadership, TfL focused most of its efforts on buy-in at middle management level. They identified “change leaders” to take ownership of changes within their areas. Change leaders took time out of the organisation to train and then pass on their learning to teams, in tandem with things like bespoke packages of change management training.

How it applies to the NHS: 1 in 10 CEO posts in the NHS are not filled substantively, like TfL the answer may lie with middle managers.

Action the NHS could take: The NHS may wish to take a holistic view of the middle manager tier in hospitals and focus on developing many of them as change leaders. Middle managers are often those who have to deal with the direct result of change, and investment in their development may boost efficiency at a local level. Junior doctors and nurses could equally be developed to be the “change leaders” in trusts.

6. Set and reach clear milestones

TfL’s experience: TfL made the time to articulate a long term programme, which clearly expressed milestones internally and, in turn, communicated them to the public. Adopting this approach created internal and external accountability, with everyone moving in the same direction.

How it applies to the NHS: The NHS may at times find it tricky to drive programmes of change, as it is typically working on short political cycles. Middle managers are often addressing operational pressures and may lack the time to implement new programmes as a result.

Action the NHS could take: The contracting cycle could perhaps be extended to last longer than one year in the NHS. The 2016/17 - 2020/21 planning guidance has introduced multi-year CCG funding allocations, yet provider activity continues to be contracted for on an annual basis. Greater clarity could be offered regarding the outcomes and milestones that need to be achieved, while progress could be actively managed against them. Milestones could be set for overall transformation and efficiency programmes.

7. Manage demand for services

TfL’s experience: Demand for TfL’s services is growing and while it has plans to grow the network to meet future demand, the first thing it did was to maximise the capacity of its existing infrastructure. It did this in a number of ways, including arming passengers with the tools and information to improve the efficiency of their own journey. Information was made more visible, accessible and standardised in stations and online and contactless payment has removed the need for customers to visit ticket machines. These changes have sped up the flow of passengers through stations, reducing congestion and alleviating capacity issues in the interim while station expansion plans are rolled out.

How it applies to the NHS: The Five Year Forward View suggests that empowering patients and communities is the key to managing future demand, particularly in relation to demand created by preventable conditions. To do this patients, like TfL’s passengers, need to be informed and armed with the tools that enable them to take an active role in their care, wholly acknowledging that self-care is much more complex than paying for a tube ticket or navigating the London Underground.

Action the NHS could take: Like TfL, the NHS needs to provide people with the information and tools to be able to manage their own condition and to know how and when to access services. NHS organisations will need to invest in providing patients with access to information about their condition and care/treatment enabled by technology and with the help of the voluntary sector, provide people with the tools to be able to manage their own condition. 


In conclusion, despite significant differences in their objectives and services, the NHS can draw on lessons from TfL. The seven key lessons, explored in conversations with senior executives from both organisations, are useful “food for thought” for NHS leaders to consider in their efforts to transform their services whilst securing efficiency gains.


  1. NHS Five Year Forward View, NHS England
  2. Evidence submission: House of Commons Health Committee inquiry on the impact of the Spending Review on health and social care, The King’s Fund, 2015.
  3. Fit for the Future: Our plan for modernising London Underground, London Overground, Tram and DLR, TfL, 2014. 
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