NHS managers and staff have to be open with each other and show mutual trust to deal with the extensive changes to the service together, Guy Lubitsh and Andrew Day

There is little doubt that the change challenge facing the NHS right now is greater than in any other sector. Leaders are overseeing an unprecedented level of reform against the backdrop of an uncertain and stringent financial climate.

‘As managers and leaders set about building and improving relationships they are often struggling with a conflicting personal agenda’

In a bid to bring about radical changes in the way healthcare is delivered, they are having to make rapid and simultaneous shifts in everything from strategy and structure to reporting relationships and the way work is organised and managed.

Ashridge Consulting conducted 18 in-depth interviews and observed the experience of senior leaders in a variety of NHS settings, including acute, primary care, strategic health authorities and mental health, over a two year period.

These focused on two key areas: how senior managers were responding to and dealing with the changes they were faced within their roles; and how they were engaging the myriad of stakeholders whose support is needed to bring about the process of change in their institutions.

The key finding to emerge was the pivotal role that mutual trust plays in creating the conditions that encourage people to collaborate across organisational, professional and political boundaries to change structures and improve services.

Complex decisions

So what do leaders need to do to facilitate the development of this all important mutual trust, so they can successfully implement the complex changes they have been charged with making?

It’s important to recognise that as managers and leaders set about building and improving relationships they are often struggling with a conflicting personal agenda.

‘Making the right decisions in the right way is critical if changes in the NHS are to be supported by the many people they affect’

They are being asked to make emotionally demanding decisions, such as making staff redundant or closing down services, which they often don’t support personally or will be adversely affected by.

One senior manager in a PCT, for example, said she fundamentally disagreed with the principle behind the reforms and the way the changes were being imposed. She was also aware that as part of the process she would almost certainly lose her job.

Her own anger and anxiety about what lay ahead made it very difficult for her to respond constructively to staff that were also angry about the changes and worried about their future. She knew other colleagues in the organisation shared her views but were unable to express them because of a directive from above that managers should not voice opposition or show any resistance to the reforms.

In addition to the challenge of maintaining morale and helping employees accept change, managers also have to make many difficult practical decisions about how services should be restructured.

Metaphorically, some managers are building new organisations, others are knocking them down, while others are renovating them. This calls for complex decisions about how to redesign services and develop the organisation structures best suited to support and deliver them.

Many of the managers studied in the research, particularly those from a clinical background, had limited knowledge of organisation design and felt unprepared and underskilled for this work.

Survival behaviour

Making the right decisions and making them in the right way is critical if changes in the NHS are to be supported by the many people they affect. The contradictions and doubts described above often, however, get in the way of the decision making process. They give rise to dilemmas, tensions, anxiety and uncertainty.

‘Our research suggests a “fight or flight” type response is prevalent in some parts of the NHS’

Managers are worried, for example, about how to transform services while simultaneously meeting operational and quality targets. They are concerned about how to balance patient care and quality with financial constraints. They are unsure about how best to communicate the rationale for a decision when it is based on sensitive and confidential information.

In this scenario, people tend to exhibit what is known as “survival behaviour”. As a result of the speed, size and ambiguity of change, they are feeling powerless, out of control and helpless. This leads to anxiety and defensiveness. People may try to protect themselves by looking after their own interests, for example. They may avoid or ignore difficult issues or attack others who they perceive as a threat.

Our research suggests that this “fight or flight” type response is prevalent in some parts of the NHS as staff attempt to manage their anxiety in the face of perceived threats and risks.

One of the best ways for the organisation to tackle this is to provide the opportunity for individuals to meet and reflect on their role, try and understand their emotional reactions and make sense together of the experience of change. It is important these sessions are “safe” spaces where people can express themselves without feeling judged or evaluated.

Political behaviour

Heightened anxiety and mistrust also led to more covert “political” behaviour, such forming of coalitions to protect interests, spreading gossip and misinformation to undermine the agenda of others, manipulation of statistics to present information in a favourable light, or deal making with other stakeholders behind the scenes.

Turning this environment of mistrust around can be challenging but there are things leaders can do to try and break the cycle and build more positive relationships.

There is no overnight solution; trust develops slowly and requires both parties to be willing to make themselves vulnerable to others. The key is for people to progressively take small risks with each other rather than giant leaps of faith to show they trust the other party.

‘Leaders also need sufficient support from others, so they can help their teams work through the process of change’

The experience of one mental health trust included in the research illustrates how this can work in practice. The executive board has established a group of 50 change agents who are working across the trust to engage staff in the process of change. They are taking a highly participative approach in which employees are being encouraged to gather stories of effective performance that represent the trust at its best.

People are being encouraged to identify the small actions and interventions they believe will lead to effective practice and which also represent the trust’s values. The whole process is allowing people to express themselves − and also implicitly telling staff that senior management trust them to act in the interests of the organisation.

Shared agenda

We observed this process over the course of a year and noticed that as it developed, managers and staff gradually became more willing to work together on a shared agenda of service improvement and to take risks in their relationships.

Managers can facilitate the development of mutual trust by openly and transparently sharing information with staff and other stakeholders, even when the information is unlikely to be received favourably. This requires managers to be explicit about what they know and what they do not know.

The research revealed that being listened to and treated with dignity and respect increases employees’ trust. Reframing changes to help staff understand how they can take control and influence the changes in their part of the system, also helped. For instance, one leader engaged her staff by saying to them: “We have a choice of how it is done rather than letting it be done to us.” 

It is also important that managers have a strong sense of personal conviction that people can be trusted. They need to show compassion for others and demonstrate empathy for the pressures and anxiety they experience in their work.

Leaders can only empathise with others if they take responsibility for their own feelings and emotions and have the emotional reserves to meet others in their distress and anxiety. This means leaders themselves also need sufficient support from others, so they can help their teams work through the process of change.

Guy Lubitsh is principal consultant at Ashridge, Andrew Day is business consultant at Ashridge.