In the first of a series of blogs for the Challenge Top-Down Change campaign, Helen Bevan outlines why she supports NHS change from the bottom up.
Across the NHS and wider health and care system we see a plethora of change/transformation/improvement programmes as our leaders wrestle with the huge demands of providing better, safer, higher volume patient care in challenging financial circumstances.
‘I have been a long time advocate and leader of this change programme approach’
Over the past 15 years the NHS has embraced the change programme as the primary vehicle for changing the way that care is organised or delivered.
In change programmes we use systematic “change management” approaches to steer and keep a grip on the change.
We set goals, define accountabilities, agree milestones and mitigate for risks.
We regard senior leadership sponsorship and engagement as a critical component for success.
I have been a long time advocate and leader of this change programme approach in the NHS, having led or facilitated more than 50 major change programmes, from ambitious local hospital transformation efforts to complex, large scale efforts to improve patient care across the entire country.
I recognise and honour the contribution that such systematic approaches to delivering improvements in quality and safety have made in the NHS.
Challenge Top-Down Change
Before we introduced the discipline of change management, there were few skills in quality improvement, huge variations in the ways that we went about change and often no holding to account for the resources invested or the outcomes achieved. Change programmes were an important step in the improvement capability maturity of the NHS.
‘Change programmes were an important part in the NHS’s improvement capability maturity’
But it’s worth reading the research evaluations of NHS change/improvement programmes commissioned by the Department of Health, the NHS Institute, the Health Foundation and NHS Improving Quality over the past 15 years.
This research demonstrates significant variation in the extent to which NHS change programmes have delivered their intended results.
It also shows that even where the change process was well managed, this was often not a strong predictive factor as to whether the outcomes were achieved. We should have changed our change practice much more than we have done as a result of these studies.
Test, fail, learn and evolve
The problem isn’t change programmes per se but the mindset that often underpins them when they are implemented in healthcare settings.
Too often “change management” or a “change programme” is based on the premise that a small number of people can envision the outcomes sought, that the change process can be controlled and that people have neutral starting points in the change.
Yet history shows us that radical, transformational change can’t be preordained in this way.
‘Radical, transformational change can’t be preordained by a small number of people’
It is a deeply emergent process and we have to test, fail, learn and evolve as we go.
Too often leaders prescribe the outcome and the method of change in a top-down way. As a result, the change is experienced by people at the front line as “have to” (imposed) rather than “want to” (embraced).
This is a breeding ground for scepticism, resistance and inability to deliver and sustain change.
The change platform
We are at a point in NHS history where, given the need for massive, simultaneous change all around us, we need to build on our existing expertise in change programmes but take it to a new level of maturity: the change platform.
Shifting to a change platform means what thought leader Gary Hamel calls “socially constructing” change; creating the opportunity for everyone in the organisation or system (and that includes service users) to help tackle the most challenging issues.
It means valuing diversity; seeking out hundreds of ideas and potential solutions through a divergent process, rather than converging thinking prematurely around a single solution.
‘Large, diverse groups of non-experts consistently outperform small groups in decision making’
A change platform is more than the positive actions of frontline activists or small scale projects that are beneficial in their own right but are usually impossible to scale up.
It offers a way of attacking the toughest system level challenges yet avoiding the downsides of many change management programmes. That’s why, after 20 plus years as a leader of large scale change in the NHS, I’ve changed my basic approach “from programme to platform”.
That’s also why, over the next few weeks we will be use a change platform approach in our campaign Challenge Top-Down Change: “tapping the collective brilliance of the NHS”.
We hope that you will add your voice and ideas to the change process and that it might inspire you to build change platforms in your own setting.
Of course, this whole approach is not “anti” top-down change; it’s the opposite.
It is about focusing leadership attention on creating an environment that is receptive to transformational change and harnessing the energy of the whole system on making it happen.
It is what our patients, service users and families need and deserve.
Helen Bevan is chief transformation officer of NHS Improving Quality