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Helen Bevan on Change Management

The NHS is undergoing mountains of change. Change that will potentially transform services for patients but high risk change with high stakes. Change gurus and researchers tell us that up to 75% of change initiatives fail to achieve their objectives. The more things change, the more they stay the same. The reality of most large scale initiatives in the NHS is that every leader has a different set of experiences and ideas about critical success factors. Our leaders tackle many change priorities simultaneously in different ways. We don’t necessarily make best use of available resources, skills and knowledge.

The change experts offer a plethora of recipes for success. Harold Sirkin and colleagues recently published their model in Harvard Business Review. The reason I take notice is that it is based on evidence from more than 1,000 change initiatives globally. They specify four common denominations that determine the outcomes of any transformation initiative. They say no other factors predict outcomes as well as these four.

The first factor is duration. An underpinning belief in many NHS change programmes is that we need to execute change quickly. Not necessarily so, say the authors. What really matters is having formal, senior management-led, review processes. A long project that is reviewed frequently and effectively is more likely to succeed than a short project that isn’t reviewed. The second factor is performance integrity. This means selecting the right mix of team members to deliver the change; the most results-orientated people with credibility and influence and effective change skills.

The next factor is commitment. The authors focus on two critical categories. There must be active, visible backing for the change from the most influential senior leaders. They say that if, as a senior leader, you feel you are talking up the change initiative at least three times as much as you need to, your organisation will feel you are backing the transformation. In addition, the change is unlikely to succeed if it is not enthusiastically supported by the people who will have to operate within the new structures and systems that it creates. Staff need to understand the reasons for the change and believe it is worthwhile. The final factor is effort. There is an NHS tendency to launch major improvement initiatives without taking account of the extra responsibilities for change projects on top of busy operational jobs. The authors assert that if anyone’s workload increases by more than ten per cent as a result of the initiative, it is likely to run into problems. Organisations need to calculate upfront how much extra time and effort will be required to execute the change and create the space for it to happen.

The authors offer a framework for organisations to score their current change efforts and predict the likelihood of a successful outcome using the four factors. Sirkin’s model is one of a number of predictive change tools currently available. I have seen them used effectively by many NHS teams. Such models help leaders to understand their state of change readiness and take actions early in an initiative to get better outcomes. Clinical colleagues particularly appreciate this robust, evidence based approach to change. Scores can be re-calculated over time at different stages in a project’s lifecycle. Most importantly, using one of these models enables a better dialogue about what needs to be done.

So, how would the overall NHS reform process score by the four criteria ? Are effective review processes built in at both local and national levels ? Do people leading the change have the appropriate skills to execute improvement ? Have our staff bought into the opportunities of a patient-led NHS ? Can the increased effort that is required to implement the reform process be contained within existing workloads ?

We need to ask these questions and we need to act on the answers.

Sirkin H, Keenan P, Jackson A, “The Hard Side of Change Management” Harvard Business Review, October 2005.

Helen Bevan is Director of Service Transformation at the NHS Institute for Innovation and Improvement.

For details of other predictive models and change readiness tools visit