Seeking the approaches that enable faster change in the complex world of health and social care
One the biggest issues facing the health sector today is being able to effect transformational change while austerity bites and organisations come under increasing pressure to balance finances and service performance.
In recent years, when performance starts to go awry the regime that often appears, drives behaviours that tighten management and ignore many key change principles, such as engagement. The result can be a short term performance improvement at the expense of medium/long term performance. I’ve seen this happen many times and as a programme professional have sadly been part of the problem, often called upon to increase the level of scrutiny and reporting required to reassure senior leaders that ‘something is being done’ about the performance problem. Very simply my role is part of a wider cause/effect cycle that I’ve observed and shown below:
The diagram shows interrelationships between elements with ‘+’ showing an increase in the described effect of the connected cause(s) and a ‘-‘ showing a decrease in effect from the connected cause(s).
The essence of this cycle is that senior leaders are put under pressure by an external organisation, be this a regulator or central office. The external pressure seeks reassurance from and holds to account senior managers for the performance of their organisation often with a very narrow and short term focus. This drives accountability through an organisation that drives increased management attention, and often project and programme professionals such as myself are brought in to strengthen these mechanisms. The need to respond quickly, means that risk appetite reduces dramatically, reducing innovation, staff and public/patient engagement, reducing delegation (i.e. more centralisation) and finally creating an increased focus on analysis of the problems. These factors then have a significant negative impact on the amount of change to rectify the financial or performance issue, then looping round to create an increased level of external assurance required, and the loop continues. Sadly, this loop reinforces the behaviours that limit change and in my experience, consume a great deal of time and create a lot of stress for many people.
So, what to do to break this loop. It’s difficult, and some will say alternatives are a ‘leap of faith’, despite there being strong evidence suggesting that tight control and performance type of management rarely works in these circumstances. It’s sad that many leaders and managers perceive the alternatives as a ‘leap of faith’, when whilst these alternatives are complex they do keep appearing in analysis of successful change. The culture in most organisations I have worked in has reinforced the belief that tight performance management is the thing to do when performance dips, indeed external regulators and central offices often demand it. Yet despite the continued failure of tight performance management and the overwhelming evidence to support alternatives, organisations continue to repeat and reinforce the cycle outlined above. If you are wondering where the evidence of alternatives is, it is very easy to find although there are many different approaches and sources, perhaps the one of the most read management articles, Leading Change: Why Transformation Efforts Fail by John Kotter may be a good place to start. It is possible that the vast range of alternative approaches is one of the reasons why these aren’t often adopted, as with other areas of life we seem to be seeking some kind of universal approach that works in all situations. For change management, I doubt this will ever be found, but there are common features, which seem to have some universal benefits. Investigating Kotter and the vast range of change management authors/literature draws out many of themes that health organisations ought to be seeking to create in order to respond to performance problems. Features like, clear problem definition, a vision that is owned by all stakeholders, people who feel empowered to make change happen, two directional engagement with all stakeholders, prototyping designs or solutions to learn what works and creating rapid cycles of Plan/Do/Study/Act.
Reflecting on my role within tight performance loops, I recall one personal experience of being asked to turnaround a failing stop smoking service (when this was a PCT performance metric), however I spent almost all of my time in the first two weeks reporting and having to listen to lectures on what to do, rather than having time to do it. I worked with my CEO to gain his support to create the time to do the change management work and break the loop, the change approach had all of the features/themes outlined above and we turned this into a success in a timescale people told us wasn’t possible. Sadly, there are many occasions where I have been much less successful in breaking the loop.
My own research of accelerators in complex change relates strongly to the themes within change management, outlined above. This research was based in real programmes of change in the health and social care sector , identifying a number of acceleration enablers that consistently appeared in the identified periods of acceleration within these programmes. These enablers could be one approach that could be used to improve performance and change management success, as they relate to both research themes and observed practice within the health sector, they are listed below:
For more information on these enablers click here.
Granted these enablers can be difficult to establish in the cultures we work in, however experience is that if you are sincere and stick at it, the majority of people will respond positively and the required performance changes will come. There are examples where similar approaches have been embedded into cultures, at scale, with astounding results (look up Virgina Mason Medical Centre, Canterbury New Zealand and Jönköping in Sweden).
Who is really taking the ‘leap of faith? For me it’s those following the tighter and tighter performance management route, as it is these organisations who, sadly are entering into a world of repeating performance problems and limited genuine change.