Arden & GEM’s Health and Care Transformation (HCT) team led a ‘barriers and limitations to improvement’ pilot assessment, with pan CSU colleagues, to support a trust experiencing performance pressures and recovery planning challenges.
Drawing on data analysis, stakeholder engagement and thematic assessment, the HCT team provided a clear evidence base to support immediate recovery planning, alongside valuable feedback to inform the revised national approach.
The challenge
Trusts facing significant operational, financial and quality pressures have been able to access structured, intensive support through the Recovery Support Programme (RSP) since July 2021. In 2025, Arden & GEM’s HCT team was commissioned to deliver a barriers and limitations to improvement pilot diagnostic, for a challenged trust in the North West.
Our approach
Arden & GEM’s HCT team applied an evidence‑based diagnostic approach to identify the underlying barriers and limitations constraining improvement.
The multidisciplinary team brought together expertise across financial performance, clinical quality, operational delivery, data and analytics, and organisational development, with support from colleagues in NHS SCW. This was underpinned by strong programme management, collaborative working with the trust and the NHS England programme team, and extensive stakeholder engagement.
Feeding into the national reset
Throughout the diagnostic, NHS England sought feedback to help shape national policy and inform changes to the assessment framework.
While early activity focused on stabilisation and immediate performance pressures, later phases placed greater emphasis on structural barriers, longstanding system dependencies and constraints beyond the trust’s direct control.
This ensured a perspective aligned to the core principles of future programmes, moving away from one‑size‑fits‑all interventions to recognise cumulative disadvantage and enable a more tailored and proportionate improvement response.
Intelligence gathering and analysis
Seven core areas of focus were used to structure the diagnostic:
- Grip and control
- Workforce capacity and productivity
- Operational delivery and efficiency
- Funding and income
- Infrastructure
- Locality and system working
- Quality and safety.
Intelligence was gathered through desktop reviews, quantitative and qualitative data analysis, and engagement with clinical, operational and system leaders.
Thematic analysis and prioritisation
Challenges were analysed and grouped into four interrelated categories:
- Operational drivers
- Systematic drivers
- Strategic drivers
- Structural drivers.
Issues articulated within the systematic and structural drivers categories could not be addressed by the trust alone. This distinction supported NHS England and system partners to differentiate between local improvement actions and those requiring regional or national intervention, such as capital investment, workforce redesign and service reconfiguration.
Where possible, the indicative financial impact of key barriers was estimated to strengthen prioritisation and investment conversations. A prioritisation matrix was developed to assess both impact and delivery complexity, with findings tested through stakeholder ‘check and challenge’ sessions.
The final outputs were a comprehensive diagnostic pack and a detailed report outlining the underlying issues and the most critical areas for targeted action.
The outcomes
The pilot diagnostic was completed during a period of severe winter pressures and national policy review. Close working between the trust, NHS England and the programme team enabled outputs that helped to inform the future direction of the assessment.
The diagnostic strengthened the credibility of recovery discussions with NHS England and system partners by providing a shared, evidence‑based understanding of what improvement was realistically achievable and where additional external intervention was required.
Key outcomes included:
- A unified understanding of barriers to improvement
- A robust prioritisation framework
- Evidence to support recovery planning and sequencing
- Alignment with the current IRP, alongside stakeholder feedback to inform future intensive support for challenged trusts.
"The programme enabled me as a new CFO to take stock of some of the wicked problems, and to focus internal attention clearly on those within the gift of the trust, and to enable appropriate discussions with partners for systemic challenges where solutions were reliant upon joint attention."
Andrew Harrison, Chief Financial Officer at Blackpool Teaching Hospitals NHS Foundation Trust
The pilot has demonstrated the critical role of engaging with provider trusts using a robust barriers and limitations diagnostic during periods of national policy change. By clearly distinguishing between controllable and uncontrollable factors, and by providing a structured prioritisation framework, the approach has supported immediate and sequenced recovery activity.
Feedback was also generated for NHS England on how future assessments can be more effectively scoped, targeted and sequenced.
"The Arden & GEM HCT team worked with us and the trust to pilot a new approach in understanding barriers and limitations impacting on providers. The team were comfortable dealing with ambiguity, worked through the challenges of delivering a new model and helped refine the approach."
Simon Gilmore, Deputy Director, National Improvement Support Team at NHS England
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