#ChangeChallenge – results of phase one
The first stage of the Change Challenge, a campaign to challenge top-down change in the NHS, has now come to an end. Working together with HSJ, Nursing Times and NHS IQ, we have engaged 1,492 people, who together have identified the barriers and building blocks of bottom-up change.
Sharing 7,500+ contributions (ideas, comments and votes) the crowd explored the following questions:
What things help or block you when you try to create bottom-up change:
- within your organisation, to improve or transform services?
- across organisations, in order to improve the health and well-being of a local population?
72% of the contributions related to what blocks or helps bottom-up change inside organisations, with 21% offering ideas for how this plays out across organisations, and the remaining 7% of contributions offered other suggestions.
Analysis of all the contributions has revealed 10 commonly occurring barriers to bottom-up change:
Our organisational strategies hold us back, they fail to provide a clear 'call to action' to change things from the bottom up. They reinforce inflexibility in our business structures, as well as leadership that is controlling.
Often there are so many priorities, it isn't clear what we should do. This leaves us fearful of stepping up without the autonomy to deliver change effectively.
Over controlling leadership
Despite some efforts, we still rely on command and control leadership rather than coaching and nurturing. We perceive that we do not have the freedom or trust to create change from the bottom up.
It's not that our leaders are bad – they just do not have the rights skills. This leaves many staff feeling afraid of speaking up, which restricts bottom-up change.
Often our leaders communicate at us, rather than with us. We are not open and transparent with each other.
We also do not have enough formal/informal ways of connecting creative people. Part of this is because there is a lack of both soft skills training and technical systems to support communication.
Poor workforce planning
It feels like we either don't have enough people or enough time to get involved in driving change from the bottom up. Some of this is because we often don't have the right mix of skills in our teams. We have a skills deficit because we are failing to nurture our people and organise the right mix of talent.
Having the right number of people with the right skills requires us to work in partnership with organisations outside our own, something we are not very good at.
There is no shortage of ideas among health and care staff. The challenge is a shortage of processes to capture ideas and a lack of leaders who truly empathise with the needs that we see.
Senior leaders are trapped in inflexible processes. And we fail to embrace ways of taking part in low cost, low risk experiments to test ideas.
We must utilise the diverse experiences of stakeholders, including our patients.
Playing it safe
Our hierarchical, centralised structures either make it too difficult to access funding and support for ideas, or we end up funding too many projects with not enough resources.
It seems that a lack of clarity on what's needed from leaders, plus a fear of doing something new from the bottom up, leaves us supporting low risk ideas involving the usual suspects.
Poor project management
When developing and implementing projects, we tend to value inputs and action rather than value and outcomes; it means we're kept busy, with no room for effective bottom-up change.
We underestimate the complexity in which we are working and we blame inflexible processes and lack of resources.
However, how change is led from the top and explained to all, and how we are trained to manage and implement projects, ultimately undermines bottom-up change too.
For us to have a positive mind-set and ultimately ensure the wellbeing of our people, we need to treat each other with compassion, as much as we would our patients. Alas, we don’t always do this.
All too often we do not feel connected to our organisation’s purpose and do not feel that we have a real stake in its future. Feeling like a cog in the engine, rather than a value-adding individual, makes us feel undervalued, disengaged and even ill. Why would we proactively get involved in change?
Our physical environment can stop us meeting people and connecting ideas. The closure of sites has put a burden on the remaining organisations. And, as we all know, our IT systems do not help us access knowledge and share information.
The incentive system and performance management regime creates disincentives to support bright ideas that might create better outcomes for patients, but which would lose the organisation income.
It creates incentives that leave us stuck habitually supporting self-serving projects.
Delving further into these barriers has revealed the 11 building blocks that the crowd feel can support bottom-up change:
Inspiring and supportive leadership
Leaders need to inspire and support their people.
This means taking forward ideas to improve their organisations based upon their quality rather than their author; a less hierarchical structure, where people have a greater understanding of each other’s roles; and “distributed leadership”, where people are trusted and talent is nurtured.
Collaboration between peers within and between organisations leads to broader operational and personal benefits.
Operationally, change programmes are more effective, allowing us to improve the outcomes for people and populations, and collaborative working builds more supportive working relationships, which is essential to improve people’s wellbeing.
Peer collaboration therefore nurtures a more positive mind-set and the desire and connections to drive bottom-up change.
Flexibility and adaptability
To deliver bottom-up change, we need flexibility within the system – both in terms of the formal organisational structure and day to day processes.
This will allow organisations, teams and individuals to more successfully adapt to the changing environment in which they are operating.
- Smart use of resources
We must try to find ways of doing more with the resources we have. The world's most successful organisations are more resourceful than their competitors. By adopting a resourceful mind-set and providing appropriate staffing and skill mix, we can try to deliver change within our current means.We should aim for smarter project selection: doing the right projects well, rather than trying to do too much with not enough resource.
- Autonomy and trust
Increasing people's sense of trust gives them the confidence and permission to deliver change. This makes the most of the knowledge and passion of people working in health and care.We need to work within acceptable clinical parameters, remove the fear associated with failure and foster a no-blame culture of reflection and learning upon what does, and what does not, work.
Challenging the status quo
Everyone is able to create and identify great ideas; organisations need to nurture and embrace the creativity of all their staff to challenge the status quo and deliver real change.
A large part of this requires health and care organisations to experiment more and share their learning, for the benefit of all.
A call to action
We must consistently articulate a clear call to action for everyone who works in health and care. To do this we need to clearly articulate the purpose and meaning of our organisations.
This will ensure alignment within organisations and across boundaries, and inspire contributions to the mission from the bottom up in a way that ensures every person is moving towards the same common goals.
Fostering an open culture
A commitment to transparency and openness creates a more positive environment. Openness allows learning to be shared across boundaries and shows to the people we serve and our colleagues that we have integrity.
The most open organisations are the most innovative.
Nurturing our people
We need to prioritise the training and development of health and care staff. However, we cannot be stuck in traditional mind-sets and must develop the right mix of skills in the right places.
This would support and nurture our people to take local leadership of the changes that are needed.
Seeing the bigger picture
- Teams and individuals need to be given the space and freedom to make long term improvement plans; large changes cannot happen overnight, and we will only be able to dramatically improve the health of populations by successfully planning for the future.
Organisations that value dissenting opinions as much as coherence and conformance are more effective at creating change; thought diversity allows the creativity of our people to flourish and good ideas to be discovered.
In phase two of the Change Challenge, which launches on Tuesday 10th February, we will be asking you to consider these barriers and building blocks and submit ideas that you think will help create bottom-up change, and also examples of how it has already been achieved.