Accelerating Change Programmes

Seeking the approaches that enable faster change in the complex world of health and social care

How to Accelerate Change In The Complex World of Health and Social Care

The NHS has made enormous progress in the quality of care since it’s creation in 1948, average life expectancy has risen by around 15 years during this period, and many of the infectious diseases of the time, are all but gone in the UK. Indeed the NHS was created in an era, where infections diseases were the key focus of the health system, however the current focus, due to increased life expectancy, is long term conditions (such as Diabetes and Heart Disease) and the continued rise of their prevalence. In recent years significant improvements in the efficiency of the health system have been made, waiting times are shorter, and patient outcomes for cancer and cardiac conditions, in particular, are better. However, the structure and culture that has been successful, is now struggling to address the current and future long term conditions epidemic. The current system will be unable to deliver the services required in a sustainable way, neither is there enough funding nor are there the numbers of specialist professionals to meet these challenges. Health and social care organisations need services and professionals to work in a more integrated manner and erode some of the professional boundaries, support people to manage their own conditions better, increase ownership of condition and management so care is more personalised and the preventable exacerbations of long term conditions are less likely. These fundamental changes in how professionals work together would reduce the need for expensive periods of hospitalisation for patients, both avoiding the requirement for more specialist staff and the anxiety and experience of a hospital stay. To ensure a sustainable health and social care system, change needs to happen quickly, and the key strategy for the sector, the ‘Five Year Forward View’, outlines the sustainability challenges of the next 5 years. Continuing to operate the current system will lead to a financial gap of £30bn within 5 years. The election promise of an additional £8bn over the next 5 years will help, however that means that the system needs to undertake fundamental changes to ensure a sustainable system within the next 5 years.

Large scale change in the sector is usually driven by a strategic planning process underpinned by a project and programme management discipline. These approaches are seen, in practice, to focus on processes and documentation and haven’t generally enabled important change management principles, such as large scale engagement of staff or public. Instead, they have encouraged a culture of performance, RAG rating and a timescales focus, rather than an understanding of the aspects of change management that enable people to change. Most organisations in the sector adapt project and programme management approaches, often by lightening the process and documentation elements, but they still use them to drive a performance and timescale focus. This isn’t creating widespread sustainable change, never mind the pace that the strategic agenda requires. Whilst project and programme management are widely used across all sectors, they were designed in and are excellent in engineering type environments. Environments where there are lots of pieces of a jigsaw that fit together and provide technical challenges when they don’t. However the change environment for large scale health and social care transformation is one where there are lots of pieces of a jigsaw,  many of them act independently in an unpredictable manner (think, flock of birds rather than a mechanical clock). Not only do the pieces in health and social care act independently, they also have much more complex interrelationships (think, about the complexity of the patient doctor relationship rather than the direct relationship between a smart phone and a mobile phone network). Project and programme management wasn’t designed with this unpredictability or complexity in mind, and whilst there are still some really important principles at the heart of project and programme management approaches, there is a need to actively understand what elements of these approaches are restricting the pace of change in complex change environments such as health and social care.

Understanding the factors that influence how transformational change can be accelerated is therefore critical to health and social care systems across England. Through interviewing people involved in five different multi organisation transformational change programmes about acceleration in their initiatives, it became clear that, there were common narratives and a surprising level of consistency in features involved in acceleration. The change approaches being used in the programmes varied significantly, with the most stark differences being that those with the strongest perceived acceleration being those that were based on emergent change, rather than driven by strategic planning processes. All had features of project and programme management, and most had been adapted and lightened, however the presence of strong or weaker project and programme management didn’t correlate with the presence of perceived acceleration, so there had to be other factors at play.

In researching the five multi-organisation programmes, three types of acceleration were identified, as follows:

  • ‘intervention points’ – points in time where clear interventions led interviewees to feel that the programme had accelerated.
  • ‘continuous’ – described by interviewees to be longer periods of time when acceleration occurred, sometimes an intervention point preceded this.
  • ‘surge’ – identified by interviewees as acceleration related to increased motivation specifically relating to positive information regarding outcome achievement.

The pattern of these acceleration types varied considerably, with two programmes dominated by intervention point acceleration, two dominated by continuous acceleration and the final programme having the early stages dominated by intervention points, with continuous acceleration dominating the later parts.

The range of people interviewed was wide and their views of when the different types of acceleration occurred varied considerably, however the consistency in the identification of continuous acceleration was significantly higher than other types, suggesting that the perception of this type of acceleration is more widely understood. Although data to support the relationship between successfully achieving objectives and acceleration wasn’t within the scope of the research, the research had the sense of a strong link between success and continuous acceleration.

So, if continuous acceleration in a complex change environment is the goal, then this research found a surprising level of consistency in the features present during this type of acceleration. Seven consistent features were identified and these seven enablers of acceleration seem to be needed to create the right conditions for continuous acceleration.

  1. Devolved decisions making with clear roles and responsibilities – the delegation of decision making to a large group, made up of a diverse group of people from front line services taking ownership for the delivery of changes.
  2. Strong Operational Relationships – time to develop and maintain these needs to be established, both informally and within a large group. This process is supported by a coordination role.
  3. Strong Operational Vision – supported by narratives to aid the development and adaption of the vision owned by a large operational group.
  4. Clear Programme Outcomes – a small number of outcomes that a large delivery group focus on and feed the intrinsic motivation associated with ‘want to’ driven change. Supported by both data and patient/people narratives and short reporting cycles for information.
  5. Sufficient resources with a balance between local operational and programme management – balancing the discipline of a programme management framework with the agility required to ‘make it happen’ operationally. Too much of one, hampers acceleration.
  6. Co-ordination Role focused on vision and outcomes rather than organisation – supporting the relationships, vision and engagement of key partners. If focused on vision and outcomes, then this role doesn’t need to be undertaken by someone independent of the organisations.
  7. Flexible Plan with Key Milestones – with high levels of flexibility in detailed activity planning, but with semi-fixed milestones that move rarely. Lots of detailed planning at the beginning aids the agility required through plan execution.

Reviewing these features, they do resonate with the increasing body of knowledge for change in complex environments, in particular the key themes that run through this literature. The key themes of the literature highlight the importance of a clear vision and objectives, these enablers highlight the importance of these, but also ensuring that these are relevant for the operational people making the changes. Literature also outlines the importance of engaging and involving the ‘volunteer army’ of operational people in change, it is particularly important that this engagement is driven by ‘want to’ rather than ‘have to’ change. Recent developments and supporting evidence in the world of project management point towards increasing use of ‘rolling wave’ planning and agile project management, both of which provide a high degree of flexibility in planning within the constraints of a wider set of milestones, supporting the final enabler of continuous acceleration.

The seven enablers above challenge strategic planning, project and programme management approaches in the sector, and health and social care organisations will need to consider how they will establish these enablers, in particular they will need to focus on:

  • Leadership that ‘initiates and steers’, rather than the prevalent strategic planning approach of ‘command and control’
  • Governance that supports delegating decision making to large delivery groups, populated with front line staff, with the role of senior staff being to unblock barriers that get in the way of the large delivery groups.
  • That resourcing of initiatives has a balance of operational staff and programme management, capable of supporting large delivery groups in developing relationships, patient narratives, outcome focused information and framework planning.
  • Creating rich narrative and information environments to enable large delivery groups to focus on outcomes.
  • Adapting project and programme management approaches to be more agile and supportive of the enablers.

The challenge of ensuring all enablers are in place to support change within the culture of health and social care in England, is significant. However, without this, we will all be stuck in an endless loop of slow change that is unable to respond to the strategic pressures of our world, and the shift to organisations equipped to deliver the long term condition explosion, and the ambitions of the ‘Five Year Forward View’.

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