Skip to content

This content is more than five years old

Blog

Is transformation in the NHS really transformational?

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.