Published: 01/09/2005, Volume II5, No. 5971 Page 19

The reforms set out in Creating a Patient-Led NHS represent a profound change in how we organise and deliver NHS services. Foundation trusts and practice-based commissioning signal a fundamental shift towards frontline empowerment and autonomy.

But can a nationally driven reform programme be the catalyst for a patientled revolution? On its own, no.

Whenever we impose change from the outside, people on the inside will want to get things back to how they were.

They do not consider that there is almost unlimited potential for doing more. Instead, they feel the anxiety and pressure that comes from someone else telling you to change, or else.

The first behavioural principle is that lasting transformation has to start on the inside. The change has to fit with an individual's views and aspirations, or it will not be sustained.

In this context, the role of NHS leaders is critical. Leaders translate the reform agenda into local goals, design and implement change and create meaning and context for individuals.

But many operate with a 'first-order' mentality towards change. Locked into the daily struggle of activity levels and quality standards, they find it difficult to perceive possibilities beyond existing realities.

Creating a Patient-Led NHS represents a 'second-order' change; a fundamental and radical reframing of systems.

The biggest challenge is mindset.

Second-order ambition cannot be achieved with first-order perspectives and methods. As Einstein put it: 'No problem can be solved from the same consciousness that created it. We must learn to see the world anew.' The most successful leaders in the new NHS are those who think and operate in a second-order way, implementing radical change strategies.

They have more optimism about the future and what they can achieve. They can share a vision, so people in their organisations can see their own situation in a different light and embrace change.

They typically focus on individuals' strengths and potential, not shortcomings. They create an appetite for change and build the capacity of their organisation to create and deliver potential improvements.

This is supported by evidence from the wider fields of organisational behaviour and cognitive psychology.

Leaders with an optimistic view of their abilities consistently outperform those who are more doubtful or realistic, even when their abilities are similar.

Second-order leaders constantly demonstrate 'self-efficacy': the belief that we have the power and skills to produce desirable results and accomplish bold goals. They consider setbacks and difficulties as solvable challenges. Individuals who question their self-efficacy create lower aspirations and achieve less.

An organisational culture characterised by optimism is also associated with better performance, together with greater perseverance in the face of challenges.

We have to put at least as much effort into the 'inside' components of transformational change as we do for external structural reform. But secondorder NHS leaders are a minority, and resolving this is the everyone's responsibility.

We need to develop enthusiasm, energy, self-belief and motivation for the next phase of the reform process.

What is our own level of self-efficacy?

How can we improve it? There is a high probability that the limitations of our own beliefs are holding back our potential and that of our organisations.

Helen Bevan is director of service transformation at the NHS Institute for Innovation and Improvement. The full version of this article is available at www. institute. nhs. uk