Is transformation in the NHS really transformational?

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Transformation – a complete change in the appearance or character of something or someone, especially so that that thing or person is improved – is fast becoming an overused word in the debate around public sector reform. As a result, it is often deemed a euphemism for delivering more with less and is at risk of becoming meaningless. There seems to be a lack of consensus on what it actually means in terms of service reform though it is often presented as a possible panacea for the many and complex challenges facing public sector organisations.

The word increasingly appears in the job titles of individuals and teams. This could be seen as a progressive step, but it also risks locating the ‘transformation agenda’ as the responsibility of a particular person or team rather than of a whole system.

In the NHS, on the whole, approaches and attitudes to transforming services do not appear to be transformational. It’s more common to see transactional mindsets and project management solutions being applied to the transformation agenda. How many of those working in service improvement have been asked for a weekly ‘highlight report’ to demonstrate progress on transformation? Or been expected to complete a risk register on transformation?  Or to attend a transformation board to account for how far they have transformed, as if it is a predictable process?

Transformation is in fact a process that begins with individuals recognising that change needs to happen in their context, and can usually be connected back to an organisation or system vision for change – but it’s first a personal process. My view is that when we are talking about the transformation agenda we are really talking about transforming people and doing things differently for better outcomes for those who receive or use services. The human response to change is complex, because change is a messy, non-linear process. It is unpredictable and difficult to chart in absolutes or step-by-step project plans with a neat beginning, middle and end.

The human response to change is complex, because change is a messy, non-linear process. It is unpredictable and difficult to chart in absolutes or step-by-step project plans with a neat beginning, middle and end.

Changing attitudes, beliefs and behaviours is also not a linear process so it makes little sense to approach the task of transformation of people and services as if it were possible to plan, predict and deliver effectively using traditional NHS models and infrastructures in a systematic way. Is the management architecture we use to monitor, manage, and control activity and targets within the NHS appropriate for the reform agenda? It doesn’t allow for dynamic progress, risk taking and the emotional space that is required for real change to occur and be sustainable.  

Perhaps it is time to acknowledge that the current architecture and regulatory obligations are not best suited to support change and reform of services and attitudes. These are all issues we'll be exploring at our leadership summit in May, as well as an upcoming report  which will look in detail at four case studies of transformational change. 

Risk taking and the ability to test and try (and fail and try again) are core components of innovation. This requires trust and permission to fail. In a system where trust is often lacking and failure can have fatal consequences it’s unlikely that meaningful change and transformation can occur. Especially in an environment of extreme financial pressure, increasing demand for services and declining staff morale. The NHS does not tolerate risk well and inevitably we will see defensive behaviours at play when risk presents itself. These are not conditions that are conducive for service transformation. They are conditions that preserve the status quo. 

Risk taking and the ability to test and try (and fail and try again) are core components of innovation. This requires trust and permission to fail.

Andy Cowper wrote recently in the HSJ that the NHS is lacking a theory of change. I would agree with this observation and add that the NHS is also lacking the basic tools (and mindsets) for effective change and instead relies on tried-and-tested transactional methods built on hierarchical structures to support change and innovation.  

 We often hear that change should be clinically led and so often we see clinicians (who already have a ‘day job’) asked to lead on transformation as if it is simply an ‘add-on’ duty that can be fulfilled alongside their current role. In addition to that we are expecting transformative mindsets from those who have traditionally been trained to minimise risk and uncertainty –  though risk and uncertainty are the exact conditions required for real change and innovation to occur. Clinically led doesn’t necessarily have to mean that clinicians lead the change, it can be more about them having a voice at the heart of what needs to change.

Given the conditions and tools we have at our disposal for transformation and those we are expecting this from, we shouldn’t be surprised that transformation of services has not yet been delivered on a large scale. We need to move towards using and recognising a variety of approaches to change that support conversations at local as well as national level.  

Until we consider seriously how we approach change it seems that transformation will not be transformational for the NHS at a systemic level.



Health centre
Comment date
01 March 2018

You are spot on. My thesis for my MBA. was on the change and culture in NHS organisations. It is easy to see all the traps we are falling into. They just need to read the havard business reviews going back over 30 years, never mind Drucker.

Dimer Caprol

Comment date
02 March 2018

I started reading this thinking "Here we go again. Yet another commentator telling us how we are doing things all wrong". Pleasantly surprised to see very accurate insight - sadly lacking in the DH, NHS England, NHSI, CQC and many hospital managers and senior doctors (although I am lucky to work with some excellent managers).


Clinical Nurse Lead Manager,
Comment date
04 March 2018

Recently had the absolute pleasure in turning our own ‘ship around’ in the form of a psychiatric hospital that had previously been failing. Empowering staff that had been previously ignored was the most powerful thing we did, accepting that some people will make mistakes and supporting them through it gave our staff the sense of ownership and when someone feels that ownership they will accept and push for your vision of world class care.

Dr Umesh Prabhu

Was MD for 13 years and transformed Wigan,
Comment date
05 March 2018

Sad reality is NHS is everyone knows the theory and everyone busy promoting their own work. True leadership is all about our actions and transforming what happens at the level of patient care. I joined Wrightington, Wigan and Leigh FT as the MD in 2010 and by 2016 the Trust was transformed. We (not I) did it by appointing 22 wonderful medical leaders and created a culture of staff happiness and implemented good governance.

Success is when we all work together for a common purpose. We implemented staff happiness culture and made staff and patient engagement as the way we do things. We promoted visible and approachable leadership and promoted just culture and fair and open culture and implemented good governance

By 2016, 450 more patients were surviving every year, 90% reduction in harm, medical leadership was diverse and the Trust received 45 awards!

Leadership is not about telling others what needs to be done or blaming others for our failures. Leadership is all about our actions. Transformation needs transformational leaders with knowledge, skills, and courage. Transformation needs a team of good leaders to implement the good system, good process and good culture at the level of patient care.

No one can transform anything sitting in the ivory tower. NHS needs kind, caring, compassionate leaders with courage and needs more and more clinical staff to take on leadership roles. This will protect patients and staff and our wonderful NHS.

Jane Quigley

Senior Lecturer,
Comment date
06 March 2018

All too often we overlook the fact that transformation is in fact a process that begins with an individual recognising that change needs to happen in their workplace. Though closely linked to organisations and service providers vision for change – it begins with a personal process and everyone is able to transform service in some way. Leadership and change in practice is about transforming people and doing things differently, improving outcomes for those who use services. As ever the human response to change is fraught with challenge, it’s complex, it requires new ways of thinking and its unpredictable and can take time and effort – however it can be transformational for services, for people and for care.
It is a challenge with everyday workloads increasing, constant financial pressures, increasing patient demands and reduced staff morale, as was seen in the recent winter pressures, to take risks looking to the future, to change and to embed innovative ways of working. This requires resilience and in the NHS change and resilience are not synonymous. As we are too aware the NHS does not accept change easily and predictably cautious or defensive reactions to change may occur, which is not conducive for service transformation, but aids self-preservation. However, change can begin with one person and taken one day at a time. Change can begin with each one of us looking to challenge the status quo!

Lorraine Rogers

Quality Improvement Manager,
Comment date
06 March 2018

Having only recently discovered that The King's Fund is a great resource for me personally, at long last, I'm finally reading something that resonates with my previous career as Transformation Manager within a large public sector organisation. Currently having experienced only a small sample of NHS complexities described above (embarking upon year five), I still can't help feeling I'm back in a 'Life on Mars' working environment, experiencing lots of unhelpful cultural traits, despite acknowledging learning from the greats such as Drucker. That said, I know I'm making a difference, supporting my new colleagues, encouraged by the fact that key people realise that the NHS needs to find its way out of 'doing' transactional business change (and mainly on their own) and starting to understand the journey to delivering transformational change in order to sustain services. There really is a difference...

Jon Cort

LiA lead, CCIO, Intensivist,
Chesterfield Royal Hospital
Comment date
08 March 2018

Excellent synopsis of an under resourced, yet ever more vital process. One has also to consider the fear culture and the lack willingness to change in middle / senior management. If they are not set free, a permission only continues culture exists...

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