David Frith leads our strategy consultancy work with NHS and third sector organisations. Here, reflecting on participating at a recent international conference on Scenario Planning and Foresight where he presented research on how scenario planning practice can be improved[1], he suggests a shift in the focus of strategic planning in the NHS.

It’s clearly the dancing season! Since the Summer, the UK has had daily TV coverage of this year’s Strictly Come Dancing escapades; one of the show’s biggest fans, Prime Minister Theresa May, danced onto the stage for her annual party leader’s speech, and; the dance bug seems to be infecting the English NHS too. Dance lessons could be available on prescription for the lonely (an issue which is fortunately getting increased attention), and NHS leaders across the land are about to engage, once again, in the corporate rain dance, otherwise known as strategic planning. NHS England’s Long Term Plan (delayed by Brexit distractions and apparent disputes around what is achievable in the given resource) initiates a cascade of planning across the 44 areas of the English NHS in response.

It was Ackoff - a pioneer of operational research, systems thinking and management science - who introduced the dancing analogy, comparing corporate planning to a ritual rain dance performed at the end of the dry season to which any rain that follows is attributed. He describes three modes of planning:




Competencies required


We have a problem to solve

Analysis, prioritisation and remedial planning

Judgement, intuition and experience


We have opportunities and threats to manage

Programmes that accelerate or mitigate already emerging futures

Experimental learning and predictive forecasting


We can see a future we want to create

Designing and creating a desired future

Vision, adaptive learning and influencing

Most planning reflects the first two modes: we are either seeking to mend something that has gone wrong or deciding how to respond to what we think is already coming down the track (good or bad).

The reactive mode is reflected in the NHS’ reliance on inspection and review as core improvement tools, as well as in the clinical strategy work taking place across local NHS areas which commonly seeks to identify then focus attention on the ‘weakest’ areas of care.

In the prospective mode, organisations and (emerging) systems take a view on what a ‘do nothing’ future looks like - the ‘counterfactual’ – and then design programmes of action in response to their predictions. This has been the basis of official planning by the 44 local systems, and its prevalence is likely to increase through the NHS’ promotion of approaches to ‘population health management’ that are derived largely from the USA insurance-based model and that focus on responding to the ‘actuarials’. NHS business cases also reflect the prospective mode, including as they do projections of up to 60 years’ income and expenditure – endless numbers on a spreadsheet providing false assurance that the future is reliably predictable.

By contrast, the interactive mode seeks, so far as is possible, to shape the future and, where that is not possible, to nurture the dynamic capabilities required to adjust to a changing environment whilst retaining its core strategic vision. It is not a mode in which the NHS is particularly comfortable or experienced. There are some exceptions:

  • In 1994, the NHS Hemingford scenarios were developed[2], exploring four plausible alternative futures the NHS might face (and they are still of value today);
  • In 1998, the NHS Confederation created the Madingley Scenarios to mark the 50th anniversary of the NHS;
  • In 2008, the North West Strategic Health Authority of the NHS created four ‘what if’ scenarios to aid discussion and reflection with a view to encouraging more strategic, forward looking strategy making[3], and;
  • In 2013, key NHS leaders participated in the development of a set of future healthcare scenarios led by the World Economic Forum.

At the Strategy Unit, we are encouraged to find NHS and third sector partners increasingly open to exploring how the future environment might evolve and how they can advance transformational plans that both shape, and are resilient against, those futures. Organisations increasingly seek to build some horizon scanning into their strategic thinking, and our scenario analysis for a new care model in Dudley reflects the scale of change being contemplated there (a multi-billion, 15-year contract).

But can there really be value in spending time contemplating the future when today’s issues are so pressing?

Evidence from research into 83 multinational European firms suggests that there is. Professor René Rohrbeck presented the findings from this research at the recent Scenario Planning and Foresight Conference at Warwick Business School. By comparing an assessment of a firm’s future preparedness (from ‘vigilant’ to ‘in danger’) with its subsequent performance, he found future preparedness to be a powerful predictor for becoming an outperformer in the industry. A public sector version of the assessment is in development.

Figure 1 - Average profitability of firms in the future preparedness levels.

So what changes should organisations make to their strategic planning practices?

One key, evidence-based[4] lesson is to ensure that strategic work (awaydays, workshops, analysis) forms part of a joined-up, ongoing and collaborative process. Without this, we simply create ‘strategy islands’ and reports that sit on managers’ shelves, adding no value to public health and wellbeing. This is why our preferred mode of working is not as consultants who descend, dictate and depart, but as partners who provide focused analysis and advice as part of an ongoing relationship.

Further support for this approach comes from Henry Mintzberg who argues that strategic planning tends to focus on a centralised and formalised approach to programming and monitoring strategic actions. This is great for providing a sense of clarity, command and control; it is less good for helping organisations work towards a shared vision in an unpredictable and ambiguous environment. So, Mintzberg reframes the task of strategic planning in terms of three functions that support strategic thinking:

  1. Supplying analysis that seeks to broaden the consideration of issues rather than to discover the one right answer;
  2. Acting as catalysts who enable frontline stakeholders to synthesise analysis and experience, aiding and encouraging managers to think strategically, and;
  3. Helping to specify the series of concrete steps needed to carry out the vision.

The challenge is for organisations to let go of an exclusive dependence on predictive analytical data that purport to capture how the future will or should unfold, and for central structures to re-evaluate how best to gain assurance on local plans.

There is a real opportunity now, for each embryonic ‘Integrated Care System’ to establish a new way of undertaking collaborative, strategic thinking. This should provide a rich understanding of the current and emerging environment (not just the predictive ‘actuarials’), describe the envisioned future local citizens, clinicians and communities wish to realise, and develop the dynamic capabilities (including how to be a self-improving system) which can pick up early signals of change in the external environment and enable a local system to make conscious, agile responses.

It’s time to give up the rain dance: it doesn’t change the weather we face, nor does prancing on the spot get us anywhere closer to where we want to be.


[1] Realist epistemology and the improvement of scenario planning practice (Frith, 2016) uses an approach based in realist evaluation (programme theory) to build an evidence base for designing effective scenario interventions.

[2] Ringland, G., Scenario Planning: Managing for the Future (Sami Consulting, 1997)

[3] Healthcare and Wellbeing: What Might the Future Hold? Four Scenarios (NHS North West, 2008).