The NHS at 70: An organizational change orientated reflection

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Post in 25 words As we celebrate 70 years of the  NHS I reflect upon a 2014 paper on change in the NHS which is due to be revised.

I have enjoyed the recent culturally important celebrations of the NHS, both for those who provide this service and those who use this service.  I had a routine appointment with a rheumatologist recently and he asked if it was OK for a school student who was thinking of a career in healthcare to observe.  I was very happy for her to observe and I played back to him how the biologic medicine he prescribed had been life-changing for myself. He knew, but my words were for the student’s ears. I was impressed that he wanted to enthuse the next generation of rheumatologists and equally that she was interested in healthcare. This is at a time when in the UK healthcare appears to be underfunded and undervalued by the government, yet simultaneously highly valued by business consultants, leadership developers, and large corporations.

I was recently alerted (tweet) to a paper The new era of thinking and practice in change and transformation: A call to action for leaders of health and care.  Change and transformation have the potential to make a positive difference in people’s lives in a manner similar to healthcare. However, equally inappropriate prescriptions may harm individuals and organizations.  I welcome notions of a new era, as sadly change leadership orthodoxy and the leading change fetish look very similar to how they looked twenty years ago.  Elements in the paper really chimed, such as notions of disruptors and radicals particularly giving them legitimacy in a very large and complex institution was encouraging.  In leading and managing change workshops, I encourage a DIY approach informed by relevant theories, models, and concepts.  I radically encourage participants to build their own models based upon their own unique context.  These notions of localized actions rippled through the paper and importantly sharing and celebrating what worked through storytelling and case studies.  Also, I really liked their notion of curating, rather than creating knowledge.  We need more curators, what I regard as scholars, people who critically interpret existing knowledge. The other theme I enjoyed was collaborative working and shared leadership with an emphasis on bottom-up approaches to change and transformation, rather than top-down mandated change. JDI – Just Do It invariably fails to engage, explain or motivate with regards to change.

Less convincing was the business as usual emphasis on leaders, leadership and leading change in the NHS, the aims even refer to ‘… develop change leaders who can accelerate change and achieve their goals.’ This emphasis upon developing NHS change leaders sounds very much like the rhetoric espoused for far too many years by the Leadership Academy, rather than real engagement with a new era of thinking and practice for the NHS. I counted the references to the stem ‘leader’ in the paper 166 references, in mitigation, this included ‘leader’ in the paper title at the head of each page. The authors attempted to temper their passion for leaders and leadership by claiming everyone was to be regarded as a leader, but by definition, if everyone is a leader no one is a leader. My own unease with the current leadership fetish is that it privileges leaders over followers and leaders over managers. If we regard leadership as relational there is a requirement for followers and by definition, these followers become subordinates in status, but also subordinates in processes of changing. I was deeply troubled to see John Kotter and Gary Hamel being celebrated as part of this new era.  If you take the time to trace the NHS change leadership fetish to its origins it goes back to eighties and nineties corporate America when businesses turned against managers and turned toward leaders and change leadership.  Writings in business practitioner magazines such as Harvard Business Review then gave legitimacy to the shift.

If the curators of knowledge as proposed in the paper had been at work twenty years ago, collecting, filtering, evaluating, contextualizing and sharing knowledge from multiple sources, the migration of American change leadership businesses practices into the NHS would have been far less likely. There is a surprising lack of empirical evidence that combining organizational change and leadership results in a successful change (filtering/evaluating). Kotter et al observed, wrote about and wrote for American corporations, he was writing about a very different country and a very different sector (contextualizing).cropped-img_6096-2.jpg

The hospital I recently visited in London, is an exemplar of best practice, externally acknowledged and confirmed through my lived experience based on having been treated there since 2010. Visionary leadership is apparent every time I visit as the physical structure of the hospital evolves.  I benefit from the latest advances in treatment, changes informed by research projects within the hospital’s own research centres.  As a patient, you have a sense of a hospital having to change and benefitting from effective change leadership.

However, I also witness a hospital being effectively managed.  Kotter et al disparaged managers and management to privilege leaders and leadership, but it was never about an either/or dualism which they encouraged.  I mentioned earlier 166 references to the stem ‘leader’, yet in the New Era …  paper there were only 2 to the stem ‘manager’, very much in line with NHS orthodoxy, but not really a new era or radical disruption of thinking.  During my hospital visits, I value the mundane aspects of how the hospital is managed, such as effective appointment management, a clean ward, effective layout, working lifts they all oddly matter to NHS patients.

I was pleased to read yesterday that the paper is being updated and I look forward to reading the updated version, both as somebody interested in organizational change, but as an NHS patient.  I have witnessed positive changes at this hospital in parallel to important continuities in how the hospital continues to operate effectively, I am still under the wonderful care of the same rheumatologist I met in 2010.  We know in studying organizational change that dualisms such as either change or continuity are problematic, there will always be a mix of change and continuities, even if at times it feels like everything is changing.  A new era of thinking and practice for me would be when we start to remember that both leadership and management have a crucial role to play in effectively delivering healthcare, rather than privileging leadership over management. In the NHS there have been changes and there are significant changes to come, but there will also be continuities, celebrating 70 years should also really be a celebration of the continuities with regards to what is good in the NHS.

Further Reading

Bevan, H. and Fairman, S. (2014) The new era of thinking and practice in change and transformation: A call to action for leaders in health and care. White Paper, Horizons Group of NHS Improving Quality. Accessed at http://aace.org.uk/wp-content/uploads/2014/08/nhsiq_white_paper.pdf

Hughes, M. (2016). Leading changes: Why transformation explanations fail. Leadership12(4): 449-469.

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