UK: Seven Lessons For The NHS: Focus On Transformation And Efficiency - What Can Be Learnt From Transport For London?

Last Updated: 14 July 2016
Article by Rebecca George OBE

Most Read Contributor in UK, August 2017

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.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on

Click to Login as an existing user or Register so you can print this article.

In association with
Up-coming Events Search
Font Size:
Mondaq on Twitter
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
Email Address
Company Name
Confirm Password
Mondaq Topics -- Select your Interests
 Law Performance
 Law Practice
 Media & IT
 Real Estate
 Wealth Mgt
Asia Pacific
European Union
Latin America
Middle East
United States
Worldwide Updates
Check to state you have read and
agree to our Terms and Conditions

Terms & Conditions and Privacy Statement (the Website) is owned and managed by Mondaq Ltd and as a user you are granted a non-exclusive, revocable license to access the Website under its terms and conditions of use. Your use of the Website constitutes your agreement to the following terms and conditions of use. Mondaq Ltd may terminate your use of the Website if you are in breach of these terms and conditions or if Mondaq Ltd decides to terminate your license of use for whatever reason.

Use of

You may use the Website but are required to register as a user if you wish to read the full text of the content and articles available (the Content). You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these terms & conditions or with the prior written consent of Mondaq Ltd. You may not use electronic or other means to extract details or information about’s content, users or contributors in order to offer them any services or products which compete directly or indirectly with Mondaq Ltd’s services and products.


Mondaq Ltd and/or its respective suppliers make no representations about the suitability of the information contained in the documents and related graphics published on this server for any purpose. All such documents and related graphics are provided "as is" without warranty of any kind. Mondaq Ltd and/or its respective suppliers hereby disclaim all warranties and conditions with regard to this information, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. In no event shall Mondaq Ltd and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use or performance of information available from this server.

The documents and related graphics published on this server could include technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Mondaq Ltd and/or its respective suppliers may make improvements and/or changes in the product(s) and/or the program(s) described herein at any time.


Mondaq Ltd requires you to register and provide information that personally identifies you, including what sort of information you are interested in, for three primary purposes:

  • To allow you to personalize the Mondaq websites you are visiting.
  • To enable features such as password reminder, newsletter alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our information providers who provide information free for your use.

Mondaq (and its affiliate sites) do not sell or provide your details to third parties other than information providers. The reason we provide our information providers with this information is so that they can measure the response their articles are receiving and provide you with information about their products and services.

If you do not want us to provide your name and email address you may opt out by clicking here .

If you do not wish to receive any future announcements of products and services offered by Mondaq by clicking here .

Information Collection and Use

We require site users to register with Mondaq (and its affiliate sites) to view the free information on the site. We also collect information from our users at several different points on the websites: this is so that we can customise the sites according to individual usage, provide 'session-aware' functionality, and ensure that content is acquired and developed appropriately. This gives us an overall picture of our user profiles, which in turn shows to our Editorial Contributors the type of person they are reaching by posting articles on Mondaq (and its affiliate sites) – meaning more free content for registered users.

We are only able to provide the material on the Mondaq (and its affiliate sites) site free to site visitors because we can pass on information about the pages that users are viewing and the personal information users provide to us (e.g. email addresses) to reputable contributing firms such as law firms who author those pages. We do not sell or rent information to anyone else other than the authors of those pages, who may change from time to time. Should you wish us not to disclose your details to any of these parties, please tick the box above or tick the box marked "Opt out of Registration Information Disclosure" on the Your Profile page. We and our author organisations may only contact you via email or other means if you allow us to do so. Users can opt out of contact when they register on the site, or send an email to with “no disclosure” in the subject heading

Mondaq News Alerts

In order to receive Mondaq News Alerts, users have to complete a separate registration form. This is a personalised service where users choose regions and topics of interest and we send it only to those users who have requested it. Users can stop receiving these Alerts by going to the Mondaq News Alerts page and deselecting all interest areas. In the same way users can amend their personal preferences to add or remove subject areas.


A cookie is a small text file written to a user’s hard drive that contains an identifying user number. The cookies do not contain any personal information about users. We use the cookie so users do not have to log in every time they use the service and the cookie will automatically expire if you do not visit the Mondaq website (or its affiliate sites) for 12 months. We also use the cookie to personalise a user's experience of the site (for example to show information specific to a user's region). As the Mondaq sites are fully personalised and cookies are essential to its core technology the site will function unpredictably with browsers that do not support cookies - or where cookies are disabled (in these circumstances we advise you to attempt to locate the information you require elsewhere on the web). However if you are concerned about the presence of a Mondaq cookie on your machine you can also choose to expire the cookie immediately (remove it) by selecting the 'Log Off' menu option as the last thing you do when you use the site.

Some of our business partners may use cookies on our site (for example, advertisers). However, we have no access to or control over these cookies and we are not aware of any at present that do so.

Log Files

We use IP addresses to analyse trends, administer the site, track movement, and gather broad demographic information for aggregate use. IP addresses are not linked to personally identifiable information.


This web site contains links to other sites. Please be aware that Mondaq (or its affiliate sites) are not responsible for the privacy practices of such other sites. We encourage our users to be aware when they leave our site and to read the privacy statements of these third party sites. This privacy statement applies solely to information collected by this Web site.

Surveys & Contests

From time-to-time our site requests information from users via surveys or contests. Participation in these surveys or contests is completely voluntary and the user therefore has a choice whether or not to disclose any information requested. Information requested may include contact information (such as name and delivery address), and demographic information (such as postcode, age level). Contact information will be used to notify the winners and award prizes. Survey information will be used for purposes of monitoring or improving the functionality of the site.


If a user elects to use our referral service for informing a friend about our site, we ask them for the friend’s name and email address. Mondaq stores this information and may contact the friend to invite them to register with Mondaq, but they will not be contacted more than once. The friend may contact Mondaq to request the removal of this information from our database.


This website takes every reasonable precaution to protect our users’ information. When users submit sensitive information via the website, your information is protected using firewalls and other security technology. If you have any questions about the security at our website, you can send an email to

Correcting/Updating Personal Information

If a user’s personally identifiable information changes (such as postcode), or if a user no longer desires our service, we will endeavour to provide a way to correct, update or remove that user’s personal data provided to us. This can usually be done at the “Your Profile” page or by sending an email to

Notification of Changes

If we decide to change our Terms & Conditions or Privacy Policy, we will post those changes on our site so our users are always aware of what information we collect, how we use it, and under what circumstances, if any, we disclose it. If at any point we decide to use personally identifiable information in a manner different from that stated at the time it was collected, we will notify users by way of an email. Users will have a choice as to whether or not we use their information in this different manner. We will use information in accordance with the privacy policy under which the information was collected.

How to contact Mondaq

You can contact us with comments or queries at

If for some reason you believe Mondaq Ltd. has not adhered to these principles, please notify us by e-mail at and we will use commercially reasonable efforts to determine and correct the problem promptly.