Transforming the NHS through second-order change

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The NHS is facing unprecedented financial and service pressures and radical change is needed to transform the delivery of health and care services to meet the challenges of the future.

While there are many examples of first-order change – which sees variations in practice within an existing system – in health services, there are fewer examples of second-order change where more transformative change creates new ways of seeing and doing things.

Here, we talk to Matthew Lewis and Julia Fernando about their work on second-order change, which includes a project to explore the barriers to and enablers for delivering this scale of change.

What is second-order change and why is it so important?

The term ‘second-order change’ is not often used in the NHS but the concept will be familiar to many. This type of change is 'radical', 'transformational' or ‘revolutionary’ (Levy 1986) and is sometimes referred to as ‘large-scale change’ that results in long-term changes to structures, processes and behaviours (Bevan et al 2011).

We think that second-order change is key to the future of the NHS, given the need to transform the delivery of health and care services to meet the challenges of the future.

At our recent leadership summit, we heard three accounts of effectively implemented, internally led, change initiatives in the NHS that helped to inform our thinking about our current project on implementing change. Joe Hall explained how the Bromley by Bow Centre was rated as ‘outstanding’ by the Care Quality Commission after involving local staff and patients in designing its services; Maxine Jones outlined how the innovative Nuka patient-oriented approach for delivering primary care services in Alaska, US, had been introduced in Scotland; and Mark Simmonds shared his experience in Nottingham of developing an electronic system that collected, analysed and presented data in a way that could improve standards of care.

Each of these case studies had elements of second-order change. The Bromley by Bow Centre were one of the pioneers of social prescribing as a way of meeting its patients’ needs, while the Nuka care model empowers individuals to take greater control of their health and wellbeing. The experience from Nottingham demonstrates how modern informatics can alert clinical teams to provide timely interventions.

What are the key barriers and enablers to second-order change?

Our research will explore this in more detail, but our initial thinking suggests that although the above examples are all very different in terms of service provision, location and type of change, they have some shared themes: committed leaders, who inspired their teams to embrace a vision; strong management structures; and the ability track progress using reliable data. In addition to this, research has shown the importance of working collaboratively to support change by ensuring appropriate skills and funding are available and ensuring that system incentives are carefully aligned (Health Foundation 2015).

Our initial ideas about barriers to change have identified lack of relevance, clarity or evidence; disengaged staff or patients; and under-resourced, unstable or isolated teams. On a larger scale, the environment can be either conducive to change, or hostile, depending on the nature of regulations and the ease with which organisations can work across boundaries.

What will your research look at?

We are currently asking ourselves: Where are the best examples of second-order change in the health service? What are the blockers and enablers? What is the lived experience of staff who are involved in or who lead this type of change?

We plan to carry out interviews with provider organisations to find out about what it feels like to go through a process of second-order change. We intend to cover the community, primary, acute and mental health sectors, with the aim of interviewing staff at different levels of each organisation. We will ask about the motivations and requirements for second-order change and discuss how risks to patient safety can be mitigated. We hope to discover what second-order change looks and feels like in the NHS and will publish our findings early in 2018.

Get involved

If you have personal experience of second-order change that you’d like to share with us then please contact Matthew Lewis ( or Durka Dougall (