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It is relatively easy to describe the challenges NHS organisations face and the changes they must make, but it is only by transforming their established ways of working that they will be able to really implement what is demanded. It is for the sake of the people in their communities, not the system leaders and politicians, that these challenges must be met.
See our recent agenda for action on tackling the growing crisis in the NHS. This blog also appears on The Health Foundation's website , as supporters of the Ready to make change programme. Related content. Report Developing collective leadership for health care Our paper argues that collective leadership, as opposed to command-and-control structures , provides the optimum basis for caring cultures.
I am keen to find out more information about the "ready to make change" work programme. I had a browse and a search of your website but can't find information.
How can I find out more about it? Log in to post comments Reply Link to comment. The culture of the NHS social services and related agencies have to realize to be successful you have to accept 'we are all in it 'together'. Bus Passes have been withdrawn from All those suffering from a Mental Illness, what are the 'Professionals' doing to put right the 'injustice' of this?
Same is true for NHS leaders. NHS is also financially challenged and target driven organisation and hence in such a culture finance and targets dominate and patients and staff suffer! This is not a criticism of any individuals as most Board and CCG leaders try their best to do a good job but sadly as they are not trained in leadership nor appointed for values and as most of them have not worked in the NHS before I am talking about NEDs they do not realise the importance of caring for staff nor the complexity of NHS system, process, team dynamics and so on.
Sadly NHS has a culture of bullying, naming, shaming, discipline, harassment, victimisation, racism and so on. In such a culture patients and staff always suffer. Unless we appoint values based leaders and managers from top to bottom of NHS who focus on culture, values, value based leadership, good governance and accountability for leaders and get staff and patient engagement right nothing will transform our NHS. All we can have is more and more gimmicks and in reality nothing really changes.
NHS is the easiest organisation to lead provided we get leadership right. We need leaders who are kind, caring, compassionate but also courageous to say 'enough is enough'. All of them were appointed for their values and not for ethnicity or gender! Of course we are not perfect and still lot more to do. But we are on the right track with our values, culture, governance, staff and patient engagement. Connecting through practice, involved participants enabling stakeholders to sign up and commit to the transformational change work by physically and metaphorically signing on the dotted line:.
I'm trying to sort out the leadership for the workstreams… So at the moment, as part of my engagement, I'm trying to identify the right people to come on board and take leadership of those workstreams. Ellen—interview 1. We didn't impose specifics on them; it was very much down to them to come up with ideas and thoughts on how they achieved that….
So it was done very much in partnership with them. Anna - interview 3. It's not come from us. We've told them we want a joined-up approach, we need to make some savings, we need the system to work in an integrated way.
They've gone away and they've designed it and delivered it. Anna—interview 3. Less successful pieces of transformational change work at the 1-year mark highlighted themes related to disconnection ; serving as a counterpoint to successful transformation requiring connections to be made. Most often disconnection was identified as challenges with senior executive staff fully supporting or engaging with the transformation, lack of shared ownership of the vision for transformation and lack of alignment across multifaceted workstreams:.
Even if your organisation looks different, what are the work streams which sit at the core of the organisation which then must pervade everything? Daniel—interview 1. Allegiance creation through connecting was seen as the core process and set of activities by which the participants of the study approached their transformational change work.
The concept of allegiance creation specifically appears under-represented within the research literature and is worthy of further investigation. Connecting occurred at three levels: relationally, through vision and purpose and through practice. Ultimately these levels all relied on participants having collaborative relationships with stakeholders of the transformation, and allegiance and connection were achieved through various means such as framing, 15 role-modelling, having honest conversations and linking workstreams into strategic groupings.
Adaptive leadership requires personal resilience and reflection, the ability to harness conflict constructively and to mobilise others to take on new roles and responsibilities. Adaptive leaders find ways to work at the edges of their authority, encouraging productive disequilibrium. The concept of adaptive leadership presented by Heifetz and colleagues and participants' leadership behaviours clearly also resonate with those qualities and capabilities described within the system leadership literature.
There are many clear parallels between the findings of this study and the key personal values, behaviours and skills demonstrated by effective system leaders. Further research may be useful to examine further the interplay between leadership behavioural preferences and how senior executives are influenced.
Taking a social constructionist perspective, leadership behaviours arise and are shaped through interaction with stakeholders within organisations and across systems.
The narratives of transformation are powerful vehicles to mobilise others and leaders can help create these through their endorsements, role-modelling and use of language. For the participants, those who appeared most successful at the 1-year point were role-modelling allegiance to their system transformation, using collegiate, system-focused language and were framing the vision for change in ways to engage stakeholders at all levels.
Another way to describe their behaviours is that participants were attempting to create social representations of the transformational change work through interpersonal communication as a means of enhancing stakeholder collectivity and cohesiveness. From any study relying on volunteer participants to recount their experience, the limitations of a self-selected sample are clear; the participants in this study may well have increased levels of confidence and self-assurance in their leadership capabilities than others within the programme group.
Interestingly, although the transformational work had not necessarily made progress at the year-end, it is apparent that the participant group were highly reflective and mature in their accounts and all appeared to be using similar behaviours to create allegiance.
Clearly too, the study involved a small number of participants and away from the core themes which were well represented across the group, some of the subthemes had weaker evidence and were less saturated. The method of template analysis allows for the testing of a priori concepts as well as allowing emergence and while highly flexible, there are limitations in the core analysis of the data being undertaken within a faculty team who all deliver teaching on the same programme.
Attempts were made to mitigate this by use of multiple rounds of peer review as well as involving coauthors not delivering programme content at the time.
The concept of allegiance creation requires further research as it appears under-represented within the literature, particularly as part of the process of transformational change, rather than as an outcome of change or behaviours towards leaders. Additionally, the participant group, although senior, were not executive leaders within the NHS eg, Chief Executive Officer.
Although it might be argued their lack of executive status allowed them greater freedom and ability to work across organisational boundaries, it will be helpful to extend the research to executive leaders to identify whether similar concepts and behaviours are present. The study provides a process and examples of behaviours of how NHS leaders attempt to undertake transformational change across organisational boundaries. The concept of allegiance creation as a primary process appears new and requires further research.
The process of connecting at different levels does reflect existing research on system leadership behaviours within a social constructionist frame.
NHS leaders require leadership skills that are highly relationally based but are also pragmatic and practical. An effective leader of transformational change might be conceptualised as principally a connector but with a system-level allegiance and loyalty.
The authors acknowledge the time and contribution to this study from the participant pairs. Contributors AT planned and conducted the study and wrote the paper.
LG and PM were involved in the analysis of the findings, peer review, and contributed to the review of the paper. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Ethics approval The Health Research Authority classified the study as service evaluation, not requiring formal ethical approval. Provenance and peer review Not commissioned; externally peer reviewed. Skip to main content. Log in via OpenAthens. Log in using your username and password For personal accounts OR managers of institutional accounts. Forgot your log in details?
Register a new account? Forgot your user name or password? Search for this keyword. Advanced search. Log in via Institution. Email alerts. Article Text. Article menu. Original research. Creating allegiance: leading transformational change within the NHS. Statistics from Altmetric. Method Recruitment and participants The main author submitted information about the study, protocol and consent forms to the UK Health Research Authority for a decision on whether the study constituted formal research requiring ethical approval.
View this table: View inline View popup. Table 1 Summary of the study participants and their programmes of work. Procedure The participant pairs were sent additional information about the study and optedin via email.
Results Based on the analysis, one core theme titled Creating allegiance to an emergent future world was generated. Figure 1 Visual representation of the core theme and primary subthemes. Figure 2 Visual representation of the theme of connecting and its subthemes. Connecting Participants engaged in various forms of connecting activities in order to create allegiance.
Relational connecting Participants described a range of ways to make connections with stakeholders to create allegiance through building high-quality relationships. Neil—interview 1 So at this point what I've agreed with the chief execs is that the honest broker in this, around representing all the providers, is Jane, and she works for everybody and all organisations. Andrea—interview 1 I think there's also something about a clarity around the structure and how I try and take what I call some of the pink and fluffy conversations or ideas and try and bit by bit put them down and layer them down and add a little bit more detail so maybe it's actually something that's on a piece of paper that people can then really start to buy into and add to.
Connecting with purpose and vision For successful transformation, participants aimed to frame the vision and ambition for transformation to make it as accessible to as many stakeholders as possible. A key means of achieving this was to translate a high-level vision or statement of future intent into everyday practice; what different practices and ways of working are required in order for the vision to be actualised: What you're looking for is to understand that this thing that's being discussed is around helping you to up-skill your staff, to develop new and innovative ways of caring for your patients, to be able to co-produce plans, and to become part of a group of providers where you can get some support going forward.
Ellen—interview 2 So, you know, we've got to have our ducks in a row with all the bits that we've learnt through the course, and preparing ourselves so that we can get them and say, 'This is the high level service spec, but how do you want this vision to rollout for you locally? Connecting through practice While the former Connecting subthemes were principally undertaken through dialogue and relationship-building, connecting through practice was predominantly activity based, structural and practical although built on collaborative relationships.
Connecting through practice, involved participants enabling stakeholders to sign up and commit to the transformational change work by physically and metaphorically signing on the dotted line: I'm trying to sort out the leadership for the workstreams… So at the moment, as part of my engagement, I'm trying to identify the right people to come on board and take leadership of those workstreams.
Ellen—interview 1 We didn't impose specifics on them; it was very much down to them to come up with ideas and thoughts on how they achieved that…. Anna - interview 3 It's not come from us. Anna—interview 3 Less successful pieces of transformational change work at the 1-year mark highlighted themes related to disconnection ; serving as a counterpoint to successful transformation requiring connections to be made.
Discussion Allegiance creation through connecting was seen as the core process and set of activities by which the participants of the study approached their transformational change work. Limitations of the study From any study relying on volunteer participants to recount their experience, the limitations of a self-selected sample are clear; the participants in this study may well have increased levels of confidence and self-assurance in their leadership capabilities than others within the programme group.
Further research The concept of allegiance creation requires further research as it appears under-represented within the literature, particularly as part of the process of transformational change, rather than as an outcome of change or behaviours towards leaders.
Conclusion The study provides a process and examples of behaviours of how NHS leaders attempt to undertake transformational change across organisational boundaries.
Acknowledgments The authors acknowledge the time and contribution to this study from the participant pairs.
NHS five year forward view. London : NHS England , Delivering the forward view: NHS planning guidance. Next steps on the five year forward view. Naylor C , Charles A. Developing new models of care in the PACS vanguards. Timmins N. The practice of system leadership. The dawn of system leadership. Stanford Social Innovation Review. Systems leadership: exceptional leadership for exceptional times. London : Virtual Staff College , Heifetz RA , Linsky M.
A survival guide for leaders. Harv Bus Rev. Leadership and leadership development in healthcare: London. Rooke D.
|Change within the nhs healthcare||Anna—interview 2. This requires not simply tinkering with organisational nbs, but transforming the way health and care are delivered to ensure long-term sustainability. Doing means treatment In the s the NHS was part of the creation of tbe welfare state, perhaps even its flagship. Transforming the UK National Health Service NHS in the 21st century has become an imperative due to increasing demand, monetary constraints and an ageing population experiencing multiple comorbidities and complex see more and social care needs. So at this point what I've agreed with the chief execs is that the honest broker in this, around representing all the providers, is Jane, and she works for everybody and all organisations. It's not come from us.|
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The NHS five year forward view the Forward View sets out a clear vision for a future NHS in England with a greater focus on prevention, patients more in control of their care, and the breaking down of barriers in how care is provided.
The aim is for this to result in leaner, more efficient, higher quality health care. So to some extent, we know what needs to be done, but do we know how the NHS can be supported to make this change happen? There is broad agreement that change needs to be locally led, with the role of national bodies being to support those delivering care. However, central policy is not yet designed effectively to support the delivery of the Forward View vision.
The experience of many working at the front line of care is that the actions of national bodies can be contradictory and unhelpful — hindering change as much as helping. Our report draws on a number of sources: our experience of supporting improvement, interviews with leaders in national bodies and professionals working on the front line, and a review of the published research and evidence. From this work, a clear picture emerges of what characterises successful change, shown through the following seven success factors:.
However, despite wide recognition of these factors, we found they are not commonly present in the NHS in England. This means efforts to improve services and drive change across health economies are more difficult than they need to be. We believe that the balance between the different approaches can be improved.
In addition, policies from the different types of approaches do not align and can be contradictory. Immediately develop a shared view of how change happens in the NHS and what national bodies should do to catalyse it This should be created with leaders of frontline services in an ongoing way and inform all national activity. Develop the current blend of organisational policies to best support change In particular, align and redefine national measures for local success, moving from a narrow view based on short-term performance to include the conditions for successful change and resilience.
Invest far more in support for change, starting with a coherent improvement strategy for the NHS in England This strategy should include concrete suggestions for how supportive approaches can make improvements in the short term ie within a year , as well as how regional support will develop over the medium to long term. Focus action on people working at the front line Policy should start with how it will support individuals to improve care.
A great deal more work is needed to establish how current staff-focused policies can be developed and aligned to support change, as well as how these blend with the prod and proactive support approaches being pursued.
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Breadcrumb Home. How can the NHS become better at change? Our new report looks at how national bodies can support and accelerate local change in the NHS. The report identifies seven success factors for change in local organisations and barriers in four main areas. To offer insights to help strengthen transformation efforts, we selected four sites that have been recognised as successful transformation initiatives.
We interviewed 42 people who were involved in leading, supporting, delivering, receiving or witnessing the changes. Our report presents stories of transformational change drawing on their collective experiences and reflections. Two key messages emerged.
First, there are groups who work tirelessly to achieve great things — the stories are a tribute to their determination, bravery and resilience. Second, there are key considerations for health and care leaders working to achieve transformational change. We hear from the leaders from our four case study sites — in Birmingham, Bromley by Bow, Northumbria and Buurtzorg —about their transformational change projects, what made them a success, what impact they had on patients and staff, and their advice for implementing transformational change in health and social care settings.
The definition of transformational change is the emergence of an entirely new state prompted by a shift in what is considered possible or necessary which results in a profoundly different structure, culture or level of performance. In health and care, the concept of transformational change is complicated by the context. The stories of Bromley by Bow, Birmingham, Northumbria and Buurtzorg illustrate that transformation is multi-layered, messy, fluid and emergent.
It is not merely about changing how a service operates, but also about shifting mindsets, changing relationships and re-distributing power. There is a tension in the current system between the time needed for transformation and the sense of urgency for it to happen. Therefore, two things are key:.
Our stories show that staff working in health and care are motivated by a vision of safe care and better ways to deliver quality. But in the face of a need to transform, there can also be a sense of inertia and preservation of the status quo. This needs further study to understand and address the underlying causes. The nature and uses of power to ensure positive impact is important.
However, they also demonstrate how old power can enable new power. A pressing dilemma for those we interviewed was how to work effectively within current system constraints while also championing fundamentally different structures to support transformation. It is likely, in the short term, that a dual focus is needed by working within existing limitations while also nurturing new ways.
In the longer term, wider debate is needed about how best to propagate these efforts through the presence of a learning and supportive system that can enable and sustain great change.
Our stories imply that the answers lie with communities and frontline staff. If that is the case, there is a need to reconsider who is leading and driving current transformational change. Across our examples, transformations were sparked by people seeing and acting on local needs.
The human motivation to make a difference was very powerful. More needs to be done to help people to nurture change sparks and bring about change. Communities also displayed the power to make change: driving health and care innovations, providing ideas that shaped new primary care models, reshaping plans for hospital provision, sparking career choices that transformed care across cities, regions and countries. There is a need to reconsider the relationship between health and care organisations and communities and service users.
Our stories suggest that technology that makes it easier and simpler for staff to do their work to provide quality support for the people who need it is critical. Data can be a powerful tool in transformation, as can stories, experiences and relationships.
Transformational efforts can be strengthened by building on this. Our stories show the need for individuals with skills to kick-start and drive through transformation in a way that is inspiring, approachable and supportive. The stories show the need to understand staff and create positive cultures that enable transformational change.
Our work on collective leadership shows the importance of developing cultures to support effective teamworking.