Change is inevitable in all organisations over time. This due to both internal and external pressures. The NHS is no exception, from its formation in 1948 it has had to respond to these pressures and adapt to keep the organisation relevant to a changing environment and population. In 1948, prescriptions were free, but prescription charges became necessary as early as 1949. In the following 65 years, the organisation has had to change in response to the advent of many technologies and treatment techniques – interventional radiology and laparoscopic surgery to name just two, whilst keeping its underlying core principles and values intact.
Therefore, the key questions for the NHS, or departments within it, are not whether to change, but:
What to change?
What to change to?
How to change successfully?
Types of organisational change are classified by the extent of the change required and the speed in which the change is to be achieved.
The extent of the change may be a fundamental change, or realignment. The speed of change may be incremental, or a ‘big bang’. An incremental realignment change might mean changing theatre start times from 0830 to 0800 and then to 0730, whereas a fundamental ‘big bang’ might mean outsourcing radiology overnight to an Australian provider.
Leaders often feel that the nature of a change is the most likely factor in determining whether the change will be successful. In fact, organisational culture more often determines whether and how an organisation adjusts to changed circumstances. Culture is the set of ‘taken for granted’ assumptions, behaviours and routines that exist in every organisation. The existing culture is inevitably embedded and resistant to change. For example, a proposal to do away with separate anaesthetic rooms for each theatre would be strongly resisted in the UK for cultural reasons, even though it works successfully in many European countries and the USA.
Resistance to change
All individuals and groups resist change when they perceive a change is a threat to them. Reasons for resisting change are often sensible, and include social, job and personal factors:
Social factors - Lack of consultation before change is made
Job factors - Fear of degradation of pay or working conditions
Personal factors - Staff feel less valued because their existing role is being removed
Leaders must be aware of these valid reasons for resisting change, and manage the change process in a way that addresses these underlying issues.
Managing the change process
A common reaction to resistance to change from leaders is to push for the change more strongly. Kurt Lewin in the 1950s suggested this would be ineffective, and proposed the three stage model of change management. He argued that, in order for change to occur successfully, organisations need to progress through three stages.
Unfreezing habits – establishing that some change to the status quo is needed
Changing to new habits – this is where the case for the specific changes is made
Refreezing to ensure lasting effects – by rewarding those who embody the new status quo
If done successfully, colleagues feel that they are driving the change process itself, rather than it being imposed on them from leaders.
Leadership style in the change process
Kotter and Schlesinger set out the following change approaches to leadership style for overcoming resistance to change:
Education and communication – a lack of information or inaccurate information can derail any change process. If informed and persuaded of the need for change, many people will help with the implementation of change. This can be time consuming if large numbers are involved, but can lay solid foundations for the refreezing process.
Participation and involvement – ideally, those affected by the change should have a role in guiding it. They will feel that the change is beneficial to them and their input will often mean that better outcomes are achieved.
This will usually be sufficient to gain enthusiasm from those who feel well equipped to deal with the change. But some will still have valid concerns.
Facilitation and support – often change is resisted because people feel they will not be able to cope with the new system. Good leaders will provide sufficient support, including training, to meet the demands of the post change environment.
Negotiation and agreement – often one group will lose out and will have the power to resist. Negotiation and tailored agreement can be a way to overcome their resistance. However, care must be taken that expensive concessions made to a specialised group do not have to be applied to everybody.
At this stage, there may be a core of people who continue to resist change for cultural or principled reasons. The remaining strategies are not ideal, but may be necessary if time is short and change is essential.
Manipulation and co-optation – this can be quick and a tempting solution but can lead to future problems if people feel they have been manipulated.
Explicit and implicit coercion – this is the quickest and can overcome any kind of resistance but is risky and may leave people angry at leaders.
Conclusion: the importance of adaptation and continuous change
Change is best when looked on not as an event but as an ongoing process, and ideally the culture within any organisation is developed in which change is embraced. Those that manage change successfully have the imagination to innovate, the professionalism to perform and the openness to collaborate.
By Ele Galtrey
North Central School of Anaesthesia
The Machine That Changed the World
by Daniel T. Jones, James P. Womack, and Daniel Roos