Making Informed

Decisions

on Change

KEY POINTS FOR

HEALTH CARE MANAGERS

AND PROFESSIONALS

What is it for?

The booklet aims to encourage managers and

clinical professionals to reflect on, and share,

learning and experience of what helps and

hinders successful change in pursuit of quality

health services.

Drawing on a focused summary of selected

models, it explores what has been learned so

far about the successful management of change.

In particular, it considers:

• What findings are of most practical use to

those delivering and organising health services

and to those receiving those services?

• Where can these lessons be found?

The NHS Plan (DOH, 2000) made it clear that

far-reaching change is needed if the health

service is to deliver the standards that patients

expect and staff want to provide. This booklet

supports the work needed at local levels to

make the plan a reality.

Who is it for?

The booklet offers findings of practical interest

to all those attempting to bring about change

for the benefit of patients. Health professionals,

managers and educators at many different levels

helped to develop the material; as did

representatives from patient, community and

user groups.

Making Informed

Decisions

on Change

This is a practical

learning resource

for all those

planning and

managing change

in the NHS.

2

Contents

Reinventing

the wheel?

As a manager or a health

professional, where can you

start in planning and putting

into practice effective change

initiatives?

4

What works?

What can you do to help

make sure that your

management of change is

based on sound evidence

and best practice?

5

Thinking about

change: a rough guide

The sheer size and scope of

the literature on change

management can make it

hard for practitioners to find

their way around. This

section offers:

• signposts through the forest

• insights into the real-life

experiences of managers

and professionals as they

bring about change.

6

Change, in practice

In practice, what are the main

factors affecting the way

managers and professionals

approach change?

19

Thinking ahead

Where can you look for

evidence, further information,

help? Should you be thinking

about people, published

resources, learning networks?

21

References 23

Acknowledgements 24

Where does it come from?

The NHS Service Delivery and Organisation

(SDO) National R & D Programme was launched

in March 2000. The remit of the Programme is

to produce, and promote the use of, research

evidence about how the organisation and

delivery of services can be improved to increase

the quality of patient care, ensure better patient

outcomes, and contribute to improved health in

the wider community.

As one of our first activities, we carried out a

national listening exercise which brought

together a wide range of people – including

service users, health care professionals, health

service managers and researchers.

One area of common concern was the

implementation and management of change.

This concern on the ground chimed with the

requirement for change in pursuit of quality set

out in the White Paper, A First Class Service

(DOH, 1998).

In response to the specific needs identified,

we have developed this publication and a longer

review, Organisational Change, under the series

title, ‘Managing Change in the NHS’. See back

cover for more information.

3

Click below for link to page required

What changes all the

time but stays the same?

According to an influential article

published three years ago, there is one

short answer to the question, ‘What

changes all the time but stays the

same?’ That answer is, ‘The NHS’.

The NHS is 50 years old. Every

government since 1948 has

re-invoked its founding principles,

but there is less agreement about

how services based on these

principles should be organised.

Alongside remarkable stability in the

espoused purpose of the NHS there

has been almost constant structural

change. […] There is a paper

mountain of advice on reforms,

restructuring and managing change.

Yet many behaviours do not change.

The puzzle is why the NHS has been

so unchanging, given the barrage of

attempts to ‘reform’ it.

Plamping (1998)

Some of those who use, work in and

care deeply about the health service

agree with this insight about behaviours

remaining the same. Others point to

the significant changes in clinical

interventions that are constantly taking

place and argue that substantial

change is already a feature of the NHS

– and that patients across the country

are benefiting as a result.

There is little disagreement on a core

issue. That, whatever its record on

change so far, the health service needs

to transform itself further so that more

and more people have improved

access to more effective services –

and feel better about the way they are

treated by the health service.

There’s agreement on something else

too. That managers, professionals and

staff in the NHS show a growing

interest in understanding how they can

develop the skills and attitudes

necessary for the kind of continuous

change and learning required in a

modern health service.

Making sense of the

pressures for change …

When asked to describe what change

means for them, managers and

professionals often talk about:

• multiple priorities competing for time

• changing external pressures

• challenging demands on staff.

All these factors may seem to have an

adverse impact on patient care.

Many managers and professionals feel

a need to bring together disconnected

external initiatives and internal

requirements into one coherent,

manageable approach.

… and planning your

next moves

So, as a manager or a health

professional, where can you start in

planning and putting into practice an

effective change initiative?

Are you …

• … about to implement a change in

your unit or organisation and would

like to review the range of

approaches you might take?

• … in the middle of a change initiative

and want to take a little time to reflect

on how things are going?

• … keen to encourage other people in

your organisation to do their best to

ensure that the way they manage

change is based on sound theory

and good practice?

Whatever the focus of your current

concerns, you’re likely to find it useful

to think about the following questions:

• What do I know about effective

change management?

• What don’t I know?

• What do I need to know in order to

initiate and sustain effective change?

• Where can I look for evidence, further

information, help? For example,

should I be thinking about people,

published resources, learning

networks?

Reinventing the wheel?

4

Why is the search for

evidence important?

Many readers will be seeking an

answer to the question ‘Does it work?’

in relation to individual models of

change management. It is important to

bear in mind that neither question nor

answer is simple or straightforward.

NCCSDO has been working closely with

colleagues across the NHS and outside

to explore the nature of evidence in the

field of change management. We

already know that managers and

professionals are keen to learn from

research and to base their decisions on

evidence. However, substantial numbers

of managers and clinical professionals

argue that much of the evidence about

effective change management is located

in the heads of practitioners and has yet

to find its way into the scholarly journals.

Evidence can usefully guide

management decision-making. But, as

discussed below, many different types

of evidence are used in this field – and

each type of evidence calls for a

different kind of review and evaluation.

What counts as

evidence?

The academic and research literature

describes a wide range of approaches

to change management, many of them

differing in emphasis and focus. What’s

more, much of the evidence generated

is from a wide variety of organisations

and from diverse methodologies

marked by varying degrees of rigour.

It is important to recognise that the

type of evidence that is useful in

change management may differ

considerably from the scientific

evidence that underpins

pharmaceutical and technological

advances in medicine.

A broad range of research methods,

including methods drawn from the

social sciences, needs to be

considered in generating evidence that

will be helpful to those who make use

of and those who deliver health care

services (Fulop et al., forthcoming).

Measuring effectiveness

is difficult

Nearly all changes have a wide range

of effects, some planned, some

unplanned. When measuring the

effectiveness of the change, you need to

take account of the full range of effects.

Change programmes involve analysing

the causes of the presenting problem,

designing the change intervention, and

implementing it. This is rarely a linear

process, moving from point A to B to C.

Characteristically, the process involves

jumping ahead, moving sideways or

backtracking – for example, using

learning from the implementation phase

to re-design aspects of the programme.

Different people involved in the change

programme will have different views of

the event or events that triggered the

programme, of the underlying causes

of the problem, and of the desirable

outcomes of the programme. So you

need to think carefully about whose

measures of effectiveness are used.

What works?

Example – Learning about, and

from, implementing change

A change initiative implemented in mental

health services for older people resulted

in improved referrals and outcomes for

patients. Those taking forward the initiative

benefited from the support of the Clinical

Governance Development Programme

(see page 21). They highlighted the

importance of others learning the following:

• A structured approach – based on a

critical review of models of change

• Staff involvement – including a

consultation process to pave the way

for change, backed up here by a

monthly bulletin

• Responsive leadership – with full

backing from the clinical management

team, e.g. when negotiating time for

communicating the change

• Avoiding change jargon – conveying

the change agenda to staff in day-to-

day terms

• Openness to unanticipated outcomes

– in this case positive, as when staff

themselves identified a case for moving

towards a central access point for

referrals.

Source: Ann McPherson, Service Manager for Older

People’s Services, Wakefield and Pontefract

Community NHS Trust.

5

Finding a path through the literature

A large body of thinking about change has been developed over the last fifty years.

The sheer size and scope of the literature can make it hard for managers and

practitioners to find their way around. Organisational Change: a Review (see back

cover) attempts to create a pathway by grouping models into four main clusters

focused on key questions:

1. How can we understand complexity, interdependence and fragmentation?

2. Why do we need to change?

3. Who and what can change?

4. How can we make change happen?

We offer here a selection of models from each cluster. These range from simple tools

and techniques to broad schools of thought to more complex ‘change packages’.

Thinking about

change:

a rough guide

6

• Weisbord’s Six-Box Organisational Model

• 7S Model

• PESTELI

• Five Whys

• Content, Context and Process Model

• Soft Systems Methodology

• Process modelling

– Process flow

– Influence diagram

– Theory of Constraints (TOC)

Why do we need

to change?

• SWOT

Who and what

can change?

• Force field analysis

• ‘Sources and potency

of forces’

• ‘Readiness and capability’

• Commitment, enrolment

and compliance

• Organisation-level

change

– Total Quality

Management (TQM)

– Business Process

Reengineering (BPR)

• Group-level change

– Parallel learning

structures

– Self-managed teams

• Individual-level change

– Innovation research

– Securing individual

behaviour change

How can we make

change happen?

• Organisational

development (OD)

• Organisational learning

and the Learning

Organisation

• Action research

• Project management

How can we

understand

complexity,

interdependence

and fragmentation?

How can we

understand

complexity,

interdependence

and fragmentation?

7

What frameworks could help?

Managers and clinical professionals are likely

to face the following kind of scenario:

“In the situation where I’m trying to achieve

change, there are no cut-and-dried solutions.

The situation is complex and dynamic. This

means that I can’t plan for everything that will

happen. And I need to take into account the

fact that any intervention I make may spark off

unplanned consequences. What frameworks

can help me to think constructively about

living with this kind of complexity?”

Approaches included here range in scope

from comprehensive methodologies to single

tools. All, however, provide insight into

potential ways of understanding and dealing

with multiple priorities and pressures.

Content, context

and process model

What is it?

This model of strategic change, based on

empirical case studies, was developed by

Pettigrew and Whipp (1991) as a means of

generating insight into why some private sector

organisations were better able than others to

manage strategic change and improve their

competitive performance. It suggests that

successful change is a result of the interaction

between:

• Content or what of change (objectives,

purpose and goals)

• Process or how of change (implementation)

• Organisational context of change (the internal

and external environment).

It is also a reminder that change is influenced by

historical, cultural, economic and political factors.

The model suggests there are five interrelated

factors important in shaping a firm’s performance:

1. Environmental assessment

2. Human resources as assets and liabilities

3. Linking strategic and operational change

4. Leading change

5. Overall coherence.

In use

This model has been widely used in analysing

and learning retrospectively from change

programmes. It was also extended and tested in

a major empirical study of change in the NHS

(Pettigrew, Ferlie and McKee, 1992).

Both versions of the model provide diagnostic

checklists which can be used to assess the

likely reception of a particular intervention in a

specific locale. The example (see left) shows

how one aspect of the model was used to help

improve change programme interventions.

Example – Preparing the

ground for change

Carrying out a situation

analysis – an activity which

identifies barriers, levers and

facilitators for change – is an

important first step in

designing a change

management strategy that

will meet local needs. This

was the finding of a study

comparing nine

implementation projects,

undertaken by the South

Thames Evidence Based

Practice (STEP) Project during

1997-2000. For instance, a

situation analysis of one

project studied (Promotion of

Continence in People over

65 years in Primary Care)

uncovered the following

barriers and opportunities:

no existing policies for

continence care; trust merger;

information systems in the

process of change; and, not

least, five concurrent audits

being undertaken by staff,

contributing to a feeling of

overload. Training

interventions were developed

to help staff respond

effectively to the challenges

revealed by the situation

analysis. Outcomes of these

interventions were: increased

skills in the identification of

symptoms; more assessments

undertaken; more treatments

initiated; and more patients

offered care pathways.

Source: Ross and McLaren (2000).

8

Five Whys

What is it?

The previous model encourages a wide-ranging,

holistic approach. If the focus is a single problem

event then such an analysis may not be necessary.

However, the interrelationships which led to the

event will still need to be considered, and one

means of doing so is to ask five ‘Why?’ questions.

In use

If a problem occurs the first ‘Why?’ question is

asked: ‘Why did this happen?’ A number of

answers may be found and for each of these the

next ‘Why?’ is asked: ‘Why is that?’ The whole

process is repeated until five consecutive

‘Why?’s have been asked and answered.

Five Whys is a simple tool that can be applied

in many situations, to get to the root of a

problem (Senge et al., 1994). It helps managers

resist the temptation to deal with symptoms

rather than causes.

She was sent by staff nurse B

to assist other staff in dealing

with another patient whose

needs were more serious

The team was about to hand

over to the next shift and while

preparing for the handover

there were fewer staff available

on the ward

The handover system needs

attention

It is a while since the handover

system was discussed on the

ward and some aspects are not

being observed

A failed to mention to B that

she had been asked to bring

a bedpan

B had not invited A to hand

back any outstanding tasks

Staff nurse B would benefit

from some training in

communication skills

Appraisal has been allowed to

slip during recent shortages of

staff

Example – Five Whys in action

Nursing assistant A failed to bring it

Problem situation: an inpatient complains that her request for a bed pan has been ignored.

9

1 Why?

2 Why?

3 Why?

4 Why?

5 Why?

What is it?

One way to get a clearer picture of the different

views and expectations involved in a change

process is to use ‘process modelling’. This is a

technique for capturing visually the dynamics of

a situation and articulating how the new one is

to be different.

Theory of Constraints is one example. It aims to

improve the performance of any organisational

process that involves a series of interdependent

steps. No attempt is made to improve the

efficiency of each step in isolation. Instead, the

process as a whole is analysed, with the goal of

identifying and addressing bottlenecks – or

constraints – that prevent the process from

increasing its output.

In use

Theory of Constraints is currently being used in

the NHS – for example, within the Radcliffe

Infirmary in Oxford – to tackle waiting lists.

Process modelling –

Theory of Constraints

Example – From fragmented to integrated care

In North Tyneside, there was an acknowledgement

that stroke patients were receiving fragmented care.

A multidisciplinary audit revealed that baseline data

were not available, there were few agreed

outcomes measures and stroke care was seen as

purely hospital based. A multidisciplinary stroke

pathway was implemented across the whole of the

medical and elderly directorate, followed by a

community stroke pathway, piloted at a local general

practice. Evaluation showed consistently high levels

of use of the pathway by professionals. Use of the

tool was regarded as one of the major components

in bringing about what proved to be a successful

change, reorienting services towards an approach

which was multidisciplinary, more community-

focused, susceptible to audit – and, crucially,

centred on the needs of patients and carers.

Source: Richard Curless, Stroke Association District Stroke Services

Co-ordinator, North Tyneside Health Care NHS Trust, Report:

April 1996-1998.

Process modelling

and associated

approaches stress

the importance of

an integrated

approach to

change and to

the planning and

delivery of services.

10

Why do we need

to change?

11

What frameworks could help?

Managers and clinical professionals are likely

to face the following kind of scenario:

“I can’t make the effort that’s needed to

bring about effective change if I’m not truly

convinced it is necessary. The same is true

of all the staff in the organisation. What

frameworks can help me to share an

understanding of why change is needed?”

In the NHS, as in other complex systems,

it is only too easy to look inwards much

more frequently than outwards – or for

attention to be focused on certain types of

drivers, such as policy directives or

performance indicators. But the real answers

to the question, ‘Why do we need to

change?’, lie in identifying and reflecting on

the gaps between what is currently being

offered and what is likely to be needed in the

next few years. Many models can help

people to explore either directly or indirectly

the rationale for change.

What is it?

Strengths and weaknesses are internal to the

team or organisation, while opportunities and

threats are external. SWOT analysis focuses

attention on the match – or lack of match –

between what the team or organisation is

geared up to offer and what the world outside

needs and wants. In doing so, it encourages

people to see their own organisation, group or

team from a range of different perspectives.

In use

The SWOT matrix (see below) is one of the most

widely used strategic planning tools. Evidence

on the relative value of SWOT as a technique is

thin on the ground. Some findings suggest that

it can result in over-long lists of factors, general

or meaningless descriptions, a failure to prioritise

issues or no attempt to verify any conclusions.

This does not invalidate the use of SWOT but

does reinforce the point that SWOT needs to be

used carefully and with the end in mind rather

than as a process in its own right.

SWOT analysis

SWOT stands for:

Strengths

Weaknesses

Opportunities

Threats

12

Internal

External

Strengths

Opportunities

Weaknesses

Threats

Who and what

can change?

13

What frameworks could help?

Managers and clinical professionals are likely

to face the following kind of scenario:

“Many different people and processes have

to be involved if change is to be effective.

What frameworks can help me to identify the

key areas for my attention?”

Since its earliest days, the NHS has been

characterised by almost constant structural

change. Change of this kind has resolved

some problems, at some times, but has left

many other deep-seated problems untouched.

There is increasing recognition that people –

individuals, teams and workforces – offer the

key to lasting change in the health service.

Many will be concerned, therefore, to know

more about working with others to create an

adaptable workforce of the kind described in

the NHS Plan (DOH, 2000) – well led and fit

for practice and purpose. Here we cover two

of the more widely used ‘packages’ that

change management consultants, among

others, have used to develop integrated

change programmes.

What is it?

The focus of TQM is on processes of work rather

than on the workers themselves. Through a

process of data collection, analysis, hypothesis

formation, and hypothesis testing, changes to

processes can be devised, and the aim is that

these changes are introduced steadily and

forever to improve quality.

In use

In recent years, TQM approaches have been

brought to health care. These aim to involve

clinical staff in quality management, suggesting

that many may need to develop skills in:

• working effectively in teams

• understanding work as a process

• collecting, aggregating, analysing and

displaying data on the outcomes of care

and also on the processes of care

• designing work processes

• collaborative exchange with patients

• working collaboratively with non-medical

managers.

Given the number and complexity of the

processes involved, TQM approaches have

understandably proved difficult to evaluate

methodically. Few empirical studies provide

comparative information about the impact of

TQM on health care organisations. Evaluations

of TQM in the NHS have found that

implementation is often piecemeal, and rarely

focused on core organisational processes – that

is, clinical practice – concentrating instead on

peripheral and administrative activities.

Total Quality

Management (TQM)

TQM refers to

a management

process directed

at establishing

organised

continuous

improvement

activities, involving

everyone in an

organisation in a

totally integrated

effort toward

improving

performance at

every level.

14

What is it?

BPR is a technique for corporate transformation

that came to prominence in the early 1990s, and

is defined as:

… the fundamental rethinking and radical

redesign of business processes to achieve

dramatic improvements in critical,

contemporary measures of performance

such as cost, quality, service and speed.

Hammer and Champy (1993)

The main concepts that underpin BPR include

the following.

• Organisations should be organised around key

processes rather than specialist functions.

• Narrow specialists should be replaced by

multi-skilled workers, often working in self-

managed teams.

• In contrast with incremental techniques such

as TQM, BPR involves total disassociation

from current practices and radical rethinking.

• The direction for the requisite radical rethinking

comes unequivocally from top management.

In use

In the NHS, evaluations at Leicester Royal

Infirmary and at King’s College Hospital, London,

found that two of the central principles of BPR –

the radical, revolutionary approach to change

and the erasing of historical context – are

fundamentally incompatible with the traditions,

culture and politics of the NHS.

A more recent evaluation has indicated that

some reengineering techniques can be used

without entailing a whole-organisation approach.

For example, the National Patients’ Access Team

includes among its initiatives the national booked

admissions programme which makes use of

reengineering or ‘redesign’ techniques. Redesign

can be defined as thinking through the best

process to achieve speedy and effective care

from a patient perspective (Locock, forthcoming).

The guiding principles of TQM and some of the

tools of BPR also make a major contribution to

the ‘Breakthrough’ programme of the Institute

of Healthcare Improvement. In time this will

generate valuable evidence in this area.

Business Process

Reengineering (BPR)

Example – Using BPR

techniques as a prelude

to change

King’s College Hospital in

London uses a range of

specific techniques for its

change programme. The

programme includes tackling

outpatients appointments

systems and helping staff

deliver bad news to patients

more effectively. Each project

starts by ‘mapping’ a

common understanding of

the current situation. This is

often done by developing a

process map – of a system,

say, or the patient’s journey

through this. This is done as

a team, with facilitation, to

reflect not what should

happen but what happens in

reality. This highly visual

method has been found to

alter individuals’ perceptions

as, for example, doctors

suddenly realise that nurses

do a range of tasks they

never knew about and vice

versa. Encouraged by these

insights, staff are more likely

to buy into the wider change

programme.

Source: Kate Grimes, Programme Leader,

Transforming Healthcare Delivery, King’s

College Hospital NHS Trust.

15

How can we make

change happen?

16

What frameworks could help?

Managers and clinical professionals are likely

to face the following kind of scenario:

“I understand the situation. I know why we

need to change. I see who and what needs

to change. But how can all this insight be

used to create a change initiative that will

really deliver the results that are needed?

What frameworks can help me?”

If implementation is thought about quite

separately from the planning and design of

a change initiative, then it is likely that the

initiative will already have failed. Successful

change initiatives hardly ever follow a simple

pattern of ‘thinking’ followed by ‘doing’.

Instead, thinking informs doing and doing

informs thinking throughout the process,

in an iterative way.

Many change management models and tools

can be used when thinking about how to

make change happen. Here we look at two

influential approaches which can be applied

at several different levels. Each suggests in

different ways the importance of learning

from change – and using key learning points

to inform the next steps.

What is it?

Less a model than a school of thought, the

concept of the Learning Organisation (or

‘learning company’) is increasingly popular as

organisations, subjected to exhortations to

become more adaptable and responsive to

change, attempt to develop structures and

systems that nurture innovation.

In use

Much of the literature prescribes how

organisations should be designed and managed

to promote effective learning. There is relatively

little systematic research to support these

suggestions. However, there is growing

consensus about the features that characterise

the Learning Organisation.

The Learning

Organisation

17

Learning Organisations have flat managerial hierarchies that

enhance opportunities for employee involvement in the

organisation. Members are empowered to make relevant

decisions. Such structures support teamwork, strong lateral

relations, and networking across organisational boundaries both

internal and external (e.g. project teams).

Learning Organisations require information beyond that used in

traditional organisations where information is generally used for

control purposes. ‘Transformational change’ requires more

sophisticated information systems that facilitate rapid

acquisition, processing and sharing of rich, complex information

that enable effective knowledge management.

People are recognised as the creators and users of organisational

learning. Accordingly, human resource management focuses on

provision and support of individual learning. Appraisal and reward

systems are concerned to measure long-term performance and to

promote the acquisition and sharing of new skills and knowledge.

Learning Organisations have strong cultures that promote

openness, creativity and experimentation among members.

They encourage members to acquire, process and share

information, nurture innovation and provide the freedom to try

new things, to risk failure and to learn from mistakes.

Like most interventions aimed at securing significant

organisational change, organisational learning depends heavily on

effective leadership. Leaders model the openness, risk taking and

reflection necessary for learning and communicate a compelling

vision of the Learning Organisation, providing empathy, support

and personal advocacy needed to lead others towards it.

Structure

Information

systems

Human resource

practices

Organisational

culture

Leadership

The main characteristics of the Learning Organisation

What is it?

This is a form of collaborative, critical inquiry

drawing upon organisational learning and usually

conducted by practitioners and managers, rather

than expert academic researchers. In the field of

health, Donald Berwick advocates the use of

small-scale, short-cycle tests based on a Plan-

Do-Study-Act learning cycle. He suggests that

this particular form of action research enables

health care teams to learn on the basis of action

and its observed effects rather than on the basis

of theory alone.

In use

Action research of this kind is now being

enacted in the NHS, for example within the

Cancer Services Collaborative.

In trying to improve the process of care,

wisdom often lies not in accumulating all of

the information but in acquiring only that

amount of information necessary to support

taking the next step.

Berwick (1998)

Action research has been used successfully in a

variety of change programmes. Success has

been found to be largely dependent on

organisational context, with difficulties rooted in

political and interpersonal conflict between

researchers and managers.

Action research

Example – Commitment

to sharing learning

about change

The West London Research

Network (WeLReN) is a

primary care research network

covering four London health

authorities. It aims to produce

in primary care high-quality

research, increased research

capacity and aims to change

the culture towards reflective

inquiring practice. A series of

educational courses help

novice researchers to develop

side by side with more

experienced researchers. As

well as randomised controlled

trials and qualitative research

projects WeLReN facilitates

participatory action research

(PAR) projects. These are

particularly suited to

researching health care

systems. Multidisciplinary

teams explore what needs to

change in different

professional groups and they

feed back this information to

the others involved to produce

cycles of research, feedback

and action. This helps people

to understand what they have

to do to implement research

findings – to move from

research to development. Paul

Thomas, founder of WeLReN,

explained: ‘The carrot and

stick metaphor is designed

for donkeys undertaking

short journeys. If we want

sustainable development we

have to equip people with the

skills and resources for a

much longer journey – and we

have to treat people properly.’

Source: Paul Thomas, Director of

WeLReN, Department of Primary Care

and General Practice, Imperial College

School of Medicine, London.

18

People will have different

starting points

In practice, what are the main factors affecting

the way managers and professionals approach

change and change management theory?

Extensive discussion with people working in a

variety of organisations and clinical settings

suggests that in everyday situations most people

are concerned about the following issues.

Who wants the change? and why?

• Where is the drive for the change coming from?

• How powerful is it?

• Is it from within the service or organisation?

or is the change being imposed upon it?

• Who is opposed to the change? and why?

Importance for the unit/organisation

• How does the change fit in with the other

performance objectives set for the unit or

organisation? What priority should be given to

this initiative?

• How radical is the change needed?

• Are we already doing something to address

the issues involved in the initiative?

Performance measurement

• Who is measuring the success of the change?

• What are their concerns and how do they

measure success?

Consultation with staff

• What professional groups are involved in or

affected by the change?

• How easy will it be to involve these groups in

discussions and in the development of a

solution?

• Are the staff groups concerned already

involved with a number of other changes?

Initial questions of the kind outlined above are

helpful in enabling managers and professionals

to orientate themselves in relation to the need

for renewed change, and to start planning and

implementing the change. But as the change

initiative gets underway, those ‘in charge’ tend

to find themselves experiencing and being

drawn into a range of tensions and dilemmas.

Change,

in practice

Example – Responding

creatively to difference

For every change initiative,

including in the same trust or

the same service, people will

have very different starting

points. In one service in our

trust, for example, people

identified a need to change

and responded positively.

In another, the service was

already seen to be performing

well, so there was resistance

from key stakeholders.

Conducting reviews of both

at the same time gave us

valuable information about

the system, as well as helping

us negotiate and disseminate

change strategies more

effectively.

Source: Ann Lambkin, Head of Midwifery

and Gynaecological Services, West Dorset

General Hospital NHS Trust.

Example – How not to win

hearts and minds

A senior management team

went away for a weekend

retreat, to look at current

issues and brainstorm about

the future. There was a fair

amount of disagreement

during the weekend but by

the time they got back to their

organisation, all storms were

spent and they had agreed on

a common approach. They

sent memos down the line,

telling middle management

what to think and do. When

some middle managers came

back with critical comments,

the reaction was ‘Ah ha! So

now we’ve identified the

change resistors!’

Source: Adapted from Weil (1993).

19

Tensions and dilemmas

Managers and professionals who have spent

even a few years in the health service will have

been affected by several waves of change

initiatives. They may well feel that each wave

serves mainly to wash away the deposits, good

and bad, left by the one before. Key words might

be ‘disconnected’, ‘fragmented’ and ‘wary’.

Managers may be familiar too with some of the

tensions and dilemmas highlighted (see left).

So, what next?

Many models offer something to those charged

with managing change. Some are more widely

implemented, some more rigorously tested.

Important lessons for future change

management have been learned within and

across different localities. Perhaps the over-

arching lessons are:

• The importance of analysing the local situation

and planning an intervention accordingly

• Every intervention will have some unplanned

consequences as well as the planned ones

• Putting evidence into practice is a lengthy and

complicated process

• Frontline staff need to be offered benefits and

research must be clearly related to current

practice (Ywye and McClenahan, 2000).

Managing

change –

the reality

Change is often imposed upon

managers to meet priorities

which differ from the priorities

perceived as most important by

the key opinion formers within

the unit or organisation – in

particular, the clinicians.

There is a tension between the

instruction to ‘gain ownership’

of a particular change initiative

and the instruction to deliver

the change quickly.

Priorities change, and so a

change programme may be

overtaken by other initiatives.

Amid new initiatives, it is very

easy to lose sight of the

original objectives of a

change programme – and only

too easy to implement a series

of actions which may no longer

be the most relevant.

Many staff members are

cynical about consultation

processes, born of experience

of ‘pseudo consultation’ and

of change associated with

curbing costs.

Change of any kind inevitably

involves some kind of loss,

which may need to be

addressed.

There is scepticism about

change techniques imported

from the private sector.

Clinicians will value evidence

about the virtues of a change in

a form with which they are

familiar, but this may not be

either available or appropriate.

There is an opportunity cost,

measured in lost patient care,

associated with time spent

planning and implementing

change.

Managers tend to stay in

post for shorter periods than

their clinical colleagues and

thus are not able to see a

change programme through

from start to finish, nor to learn

from the results.

20

Read? Talk? Listen?

Whatever the focus of your current concerns,

you’re likely to find it useful to:

• consult the resource and reference tool in the

same series as this booklet – Organisational

Change (see back cover for further details)

• talk to specialists in change management –

inside and outside your own organisation

• link into the NHS Learning Network

• seek out further research evidence on

organisational change.

Working with specialists

in change management

There are people you can access who have

considerable experience and knowledge of

change management in health care. Often they

can be found in Human Resource (HR)

departments, Lifelong Learning teams, or

Clinical Governance units. If you cannot locate

them in your own organisation, your Regional

Office of the NHS Executive will be able to point

you in the direction of a local resource.

What kind of help might be available?

See right for some examples of issues

associated with change management that have

usefully been raised at exploratory meetings

between clinicians and change specialists.

Of course, those driving forward change often

want to extend their own repertoire of skills and

knowledge, as well as make effective use of

change specialists. In these circumstances, there

is a need for training and development grounded

in theory as well as in real life management

issues. The NHS Clinical Governance Support

Team, based in Leicester, offers an initiative to

support this kind of development (see page 23).

Thinking ahead

‘Can you help?’

“The success of my change

programme depends on people

from different clinical

backgrounds working together

with mutual respect and

understanding. We’ve a long

way to go to achieve this. Can

you help facilitate an initial

discussion with a range of

professionals? Are there any

structured ways of doing this

that would be helpful?”

“Can you point me in the

direction of someone who has

prepared a good project plan

based on a critical path?”

“Can you help our team do a

SWOT analysis? We’re pretty

clear about our strengths and

extremely clear about our

weaknesses, but we’re not so

clear about opportunities and

threats. We’ve all got a feeling

that there’s a lot going on

outside the organisation that

we never get a chance to catch

up on.”

“Can you help us evaluate the

changes we are about to make?”

21

Linking into the NHS

Learning Network

The NHS Learning Network was developed in

response to the reality of the pressure on time

experienced by many NHS staff and managers.

Often agendas are full, and there seems little

‘headroom’ for learning about how others in the

health service are facing and tackling common

issues – particularly how to improve and

manage services.

Using a range of approaches, including the

internet and the telephone, the NHS Learning

Network aims to:

• provide busy staff with practical help in

modernising services and raising clinical

standards

• ensure that the considerable expertise within

the NHS is shared and used effectively – for

example, linking into the Learning Network

enables users to share their learning directly as

well as benefit from the experience of others

• provide support to those leading and

managing change.