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The story of Change Day


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The story of Change Day - a learning report 2013 …

The story of Change Day - a learning report 2013
The purpose of this report is to explore what can be learned from NHS Change Day 2013. Its intent is to summarise the lessons described by those who took part in NHS Change Day; it is not a formal or independent evaluation. The report offers a narrative of what happened, explores the
ways in which people led and pledged their support of NHS Change Day, highlights lessons learned, and discusses the strengths and challenges of this approach. The report draws on interviews with core leaders, clinical and non-clinical staff, the NHS Change Day website and a catalogue of materials. It describes the immediate and ongoing impact of NHS Change Day through examples and stories that raise strategic questions for those involved in future Change Days and similar efforts.

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  • 1. NHS CHANGE DAY Do something better together Leaders Everywhere The story of NHS Change Day A learning report 2013 #NHSChangeDay By Kate B. Hilton & Chris Lawrence-Pietroni NHS Change Day is supported and coordinated by NHS Improving Quality.
  • 2. PURPOSE, DESIGN & AUTHORS OF THE LEARNING REPORT The purpose of this report is to explore what can be learned from NHS Change Day 2013. Its intent is to summarize the lessons described by those who took part in NHS Change Day; it is not a formal or independent evaluation. The report offers a narrative of what happened, explores the ways in which people led and pledged their support of NHS Change Day, highlights lessons learned, and discusses the strengths and challenges of this approach. The report draws on interviews with core leaders, clinical and non-clinical staff, the NHS Change Day website and a catalogue of materials. It describes the immediate and ongoing impact of NHS Change Day through examples and stories that raise strategic questions for those involved in future Change Days and similar efforts. Kate B. Hilton and Christopher Lawrence-Pietroni authored this report. In 2010-11, Kate and Chris supported the QIPP workstream team on mobilising for cost and quality by developing distributed leadership skills and adapting a community organizing framework to the NHS (resulting in Call to Action: Delivering QIPP and achieving common purpose through shared values and commitment). Having been mentored for years by longtime organiser, Marshall Ganz, Kate and Chris consult with organisations and voluntary multi-stakeholder groups to achieve shared purpose around health transformation. Their biographies are attached as appendices to this report. Kate and Chris wish to express their gratitute for the opportunity to learn alongside those participating in NHS Change Day, and thank all those who kindly volunteered their time to share their insights, experiences and stories. Front cover: Picture taken on NHS Change Day 2013 at Healthcare Innovation Expo. 2 Leaders Everywhere The Story of NHS Change Day
  • 3. CONTENTS EXECUTIVE SUMMARY 4 INTRODUCTION & ORGANISATION OF THE LEARNING REPORT 7 CHAPTER 1: THE NATIONAL STORY 1.1 A Time of Enormous Challenge 1.2 The Birth of NHS Change Day 1.3 From Zero to 189,000 Pledges 1.4 Summary of Quantitative Research and Results 11 11 12 14 16 CHAPTER 2: THE PLEDGE MAKERS’ STORY 2.1 The Story of NHS Arden Commissioning Support 2.2.The Story of Open Minds Alliance CIC 2.3 The Story of Derbyshire Community Health Services Trust 2.4 The Story of Steve Fairman, NHS England 19 19 22 24 28 CHAPTER 3: LEARNING FROM NHS CHANGE DAY 2013 3.1 ‘Impact’ or ‘Design and Outcomes’? 3.2 Design: NHS Change Day, Social Movements and Hierarchy 3.3 Outcomes: Distributed Leadership 3.4 Outcomes: Relationships 31 31 33 33 36 Leaders Everywhere The Story of NHS Change Day 3.5 Outcomes: Weak & Strong Ties 3.6 Outcomes: Voluntary Action 3.7 Outcomes: Mobilisation around Shared Values 3.8 Outcomes: Collective Action 3.9 Outcomes: Social Media 3.10 Outcomes: A Special Kind of Grasstops Leadership 3.11 Outcomes: A ‘Dual Operating System’ 38 39 40 41 42 44 47 CONCLUSION: LEADERS EVERYWHERE 49 RECOMMENDATIONS 51 REFERENCES 55 APPENDICES Appendix A: The Story of Barking, Havering and Redbridge University Hospitals NHS Trust Appendix B: The Story of Birmingham Children’s Hospital Appendix C: The Story of Jonathan Griffiths Appendix D: Authors’ Biographies 57 57 63 66 70 3
  • 4. EXECUTIVE SUMMARY NHS Change Day 2013 was the biggest day of collective action for improvement in the history of the NHS. A countrywide event in England, NHS Change Day was a grassroots initiative devised and driven by a small group of emerging clinicians and improvement leaders. Their idea was to create a mass movement of National Health Service (NHS) staff demonstrating the difference they can make by one simple act, proving that large-scale improvement is possible. The NHS Change Day core leadership team applied and adapted social movement theory, skills and practices associated with community organising and made use of social media to secure voluntary pledges from NHS staff and patients to take a specific improvement or innovation action on or around 13 March 2013. The Change Day team set themselves the goal of securing 65,000 pledges, 1000 for each year of the NHS. Over 189,000 pledges were secured on the online pledge-wall alone. Learning from NHS Change Day 2013 The most significant learning from NHS Change Day is that change of this kind is possible; the most significant impact is that tens of thousands of staff have now had the experience of taking part in collective action for change. NHS Change Day was an entirely voluntary effort that invited staff to take action on something that they were passionate about. It intentionally drew on shared values, and in doing so, it unlocked willing commitment to act rather than hierarchical compliance. Putting shared values at the heart of the Change Day provided an authentic ‘call to action’ to which others with a similar outlook responded. It made Change Day not only an opportunity to do something that would be of benefit to others, but also to express support for the NHS as an institution and the shared values that it represents. Change Day occurred in a context in which the NHS was under great financial, organisational and reputational strain. This combination of factors created a climate in which NHS staff were under internal pressure and negative external scrutiny. NHS Change Day 2013 connected with that moment, providing an opportunity to transform anger or frustration into constructive action. NHS Change Day created a sense of urgency by focusing on a single day of collective action. In many cases Change Day provided the necessary prompt to galvanise and amplify activity that was already planned. Narrative skills were used to heighten and maintain this urgency and to sustain motivation. This learning report was commissioned to tell the story and capture the learning from NHS Change Day 2013. It draws on interviews with core leaders, clinical and non-clinical staff, the NHS Change Day website and a catalogue of materials. It describes the immediate and ongoing impact of NHS Change Day through examples and stories that raise strategic questions for those involved in future Change Days and similar efforts. NHS Change Day had a low threshold for participation encouraging pledge-makers to identify their own action rather than sign up to a single national initiative. This reinforced the model of distributed leadership intentionally applied by the NHS Change Day team, designed to support the development of ‘leaders everywhere.’ The design of NHS Change Day was unique precisely because it drew together networks of 4 Leaders Everywhere The Story of NHS Change Day
  • 5. grassroots leaders while also enabling leaders with positional authority to role model change leadership in a new way. No permission was sought or given for NHS Change Day to take place; it arose from the initiative of those motivated to take part. In a traditionally hierarchical environment like the NHS this modelled a profound shift in thinking and behaviour. NHS Change Day was designed to be relational, which is one of the reasons it was so successful. Off-line teams made commitments to each other supported by the online pledges made on the Change Day website. The social media presence supported the development of a community through one-to-one communication via Twitter, shared YouTube videos and other interactions. The relational nature of Change Day extended to many of the pledges themselves. A key insight arising from this experience is the importance of face-to-face human interaction not only in relation to patient care but also feedback and communication between the NHS and the public and amongst NHS staff. Because NHS Change Day was relational it developed new social capital. These new relationships have an intrinsic value for the people involved, offer a wider benefit for other NHS objectives, and provide new resources on which NHS Change Day 2014 can draw. Leaders Everywhere The Story of NHS Change Day As with many social movements, young leaders played a particularly important role in providing the energy that initiated NHS Change Day. However, NHS Change Day was simultaneously built on a foundation of learning about social movements and the application and adaptation of community organising skills in a healthcare setting amongst improvement leaders over many years. In September 2013, NHS Change Day was a winner in the Harvard Business Review / McKinsey Leaders Everywhere Challenge. Conclusion NHS Change Day offers an example of how new leadership can be developed and deployed in healthcare. This model enables distributed leadership to flourish while not ignoring the realities of hierarchical structures and processes. There is often a tension between the commitment-driven volunteerism of a collective day of action – which can be unpredictable – and the temptation by senior leaders to require certainty, specified results or perceived success. In learning to embrace this tension, and to resist the pull towards more familiar behaviours and processes, the possibility emerges for a new kind of organisation that has at its disposal both the standardising potential of hierarchy and the relational potential of networks. 5
  • 6. Summary Recommendations Engaging with existing NHS processes: NHS Change Day 2014 should remain outside the formal NHS communication, improvement, training or management structures. Senior Leaders: Senior leaders should be encouraged to pledge as part of NHS Change Day 2014 and should take the opportunity to model the value of enabling others to lead using their positional authority to hold up the successes and stories of pledge-makers. Structure: NHS Change Day 2014 should develop a more intentional structure of distributed leadership that allows teams throughout the country to take responsibility for particular aspects of the overall strategy (based on geography, professional groups, particular pledges, necessary functions or some combination). Their roles should be clearly defined and the core leadership team should in part be drawn from them. Skills and capacity: Planning for NHS Change Day 2014 should make the most of new skills that have been developed by creating opportunities for them to be passed on to others through trainings, webinars, online skills sharing, printed and online resources etc. Emerging leaders: The growth strategy for NHS Change Day 2014 should include a focus on identifying and recruiting young leaders from all parts of the NHS. Patients and their families: The strategy for NHS Change Day 2014 should consider what resources patients, their families and citizens in general can contribute to the overall effort, as well as its leadership. 6 Integrate online and offline strategies: The strategy for NHS Change Day 2014 should include an online/offline element that draws inspiration from contemporary campaigns and social movements. Build on successes: NHS Change Day 2014 should build on the successful pledges in 2013, particularly those that mobilised large numbers of people within a particular organisation or locality. Campaign approach: An annual campaign to hit a target number of pledges on a particular day each year is central to the Change Day design. While making room for new thinking, leadership and learning, a longerterm ten-year strategy for Change Day can help guide its growth with year-round activity. Goals and metrics: NHS Change Day 2014 should set an even more ambitious goal for the number of pledges secured. Additional metrics should be considered including: impact measures directly from pledges, impact measures of effects of pledges on involved patients and staff, and metrics around NHS Change Day design elements. Opportunities for research: Change Day leadership, pledge-makers and researchers should come together to pursue research partnerships, particularly around demonstrating impact from pledges and pledgemakers involved in Change Day. Global movement: The NHS should invite others to join them in a worldwide “Change Day” with no one particular organisational affiliation, but the same approach and objectives. Leaders Everywhere The Story of NHS Change Day
  • 7. INTRODUCTION & ORGANISATION OF THE LEARNING REPORT NHS Change Day 2013 was the biggest day of collective action for improvement in the history of the NHS. A countrywide event in England, NHS Change Day was a grassroots initiative devised and driven by a small group of improvement leaders and young and emergent trainee clinicians. Their idea was to create a mass movement of NHS staff demonstrating the difference they can make by one simple act, proving that large-scale improvement is possible. The effort was designed to engage the frontline in individual and team pledges to improve patient experiences or clinical outcomes by spreading and adopting best practices and championing innovation. The aim was for 65,000 pledges to be made, 65 being the number of years the NHS has been in existence. Over 189,000 pledges were made. This report explores some of the learning from this inspiring effort. It is organized into three chapters: (1) narrative of Change Day; (2) learning from pledges, and (3) lessons from the approach. In Chapter One, we offer a narrative of Change Day by describing the challenges facing the NHS at the time, the birth of Change Day as an idea, the leadership that took it forward, their strategy to reach their goal, and a summary of quantitative results. In Chapter Two, we offer the qualitative examples of four pledges to learn what Change Day meant to pledge-makers, and what pledge-makers meant to Change Day. In Chapter Three, we explore our learning about this approach to change by examining its design elements and considering the range of outcomes that flowed from them, the challenges and limitations that emerged, and opportunities for development in the future. We conclude this report with a brief summary of what we view as our greatest takeaways from NHS Change Day and its implication for health care organisations the world over. Leaders Everywhere The Story of NHS Change Day HOW TO READ THIS REPORT NHS Change Day 2013 was the biggest day of collective action for improvement in the history of the NHS. A countrywide event in England, NHS Change Day was a grassroots initiative devised and driven by a small group of improvement leaders and young and emergent trainee clinicians. Their idea was to create a mass movement of NHS staff demonstrating the difference they can make by one simple act, proving that large-scale improvement is possible. In September 2013 NHS Change Day was a winner in the Harvard Business Review/McKinsey Leaders Everywhere Challenge. The effort was designed to engage frontline staff in individual and team pledges to improve patient experiences or clinical outcomes by spreading and adopting best practices and championing innovation. The aim was for 65,000 pledges, 65 being the number of years the NHS has been in existence. In the event over 189,000 pledges were made. Chapter 1: The National Story Stories are at the heart of all successful social movements; they are used to call others to action, to sustain motivation in difficult times and to celebrate what has been achieved. In Chapter 1, we tell the story of NHS Change Day from the perspective of the national leadership team that brought it into being. How and why did it happen? How did this team come together? How did they come up with the idea? How did they work together? What challenges did they face? How did they overcome them? What have they learned and what would they do differently? If these questions are of interest, you’ll find answers in sections 1.1-1.3. Quantitative results of NHS Change Day 2013 can be found in section 1.4. 7
  • 8. Chapter 2: The Pledge-Makers’ Story Stories are endlessly variable and can be retold in many ways. In Chapter 2, we tell the story of NHS Change Day from the perspective of the people who made it happen on the ground – the pledge-makers. To do this, we dive into four case studies, each of which illustrates a different kind of pledge with diverse challenges, choices, outcomes and learning. In section 2.1 the Story of NHS Arden Commissioning Support explores the unexpected benefits of participating in Change Day from a group that did not initially connect with its approach, and the surprisingly powerful impact of a pledge that engaged staff and citizens in face-to-face relationships. In section 2.2 the Story of Open Minds Alliance Community Interest Company reveals how a single pledge led to over 50,000 supporters, and how Change Day enabled an organisation outside the NHS to build thousands of relationships inside the NHS, each of which has the potential to improve the health and wellbeing of some of the most vulnerable people in England. In section 2.3 the Story of Derbyshire Community Health Service Trust illustrates how Change Day was used as a catalyst to amplify work that is already underway, how the creativity of staff was unleashed (look out for the Harlem Shuffle), and how supporting pledges at a local level helped to ensure sustainable impact. 8 In section 2.4 the Story of Steve Fairman, NHS England shows how action by a single pledge-maker had unpredictable knock-on effect that led to a chain of new insights and relationships, and the impact of a pledge that at its simplest involved spending time in someone else’s shoes. Three additional case studies can be found in Appendices A-C. • In Appendix A the Story of Barking, Havering and Redbridge University Hospitals NHS Trust explores the pledges of three different leaders and how they worked to enable others to exercise leadership. • In Appendix B the Story of Birmingham Children’s Hospital illustrates the impact that a single enthusiastic individual can have by motivating others, and how an institution like a hospital can replicate the Change Day model locally, generating hundreds of pledges and sustained change. • In Appendix C the Story of Jonathan Griffiths shows how social media played a role in raising awareness of Change Day and building a national community of collective actors, as a GP spent the day in a wheelchair in order to better understand one subset of patients. We have drawn extensively on lessons and examples from the appended case studies in Chapter 3 of this report and included them in full as an additional resource. Leaders Everywhere The Story of NHS Change Day
  • 9. Chapter 3: Learning from NHS Change Day 2013 This report aims to tell the story of NHS Change Day 2013 and to extract the learning from that story. In Chapter 3 we draw the learning together. Section 3.1 ‘Impact’ or ‘Design and Outcomes’? looks at the thorny issue of how to measure the success of NHS Change Day 2013. What was its short, medium and long-term impact, and what are the best metrics for judging it? Is it possible to measure traditional improvement impacts and how valuable would it be to measure new capacity for action? What metrics should NHS Change Day 2014 adopt? Section 3.2 Design: NHS Change Day, Social Movements and Hierarchy considers what effect the application of social movement theory had on the design of NHS Change Day, how this was adapted for use in a vast hierarchical organisation, and what effect this had on the kinds of outcomes that NHS Change Day can enable. Section 3.3 Outcomes: Distributed Leadership explores the model of leadership used and developed by NHS Change Day, the extent to which this is valuable within the NHS and the challenges this poses. Section 3.4 Outcomes: Relationships looks at the importance of offline relationships in building and sustaining NHS Change Day, recruiting new leadership to it and the legacy of these relationships in terms of new social capital. Section 3.5 Outcomes: Weak & Strong Ties digs a little deeper into the nature of the relationships formed through NHS Change Day, the particular value these added to the effort and the value they could add to the NHS in future. Leaders Everywhere The Story of NHS Change Day Section 3.6 Outcomes: Voluntary Action investigates a fundamental principle that underpinned Change Day, what difference it made to outcomes and the challenges of sustaining this within the NHS. Section 3.7 Outcomes: Mobilisation around Shared Values looks at the positive vision of NHS Change Day and how this was used as a way of motivating others to take action through narrative and stories. Section 3.8 Outcomes: Collective Action shares learning from pledgemakers and others about the experience of participating in a single day of action and the effect that this had. Section 3.9 Outcomes: Social Media draws together insights on the extraordinary role that a range of social media and online technology played in enabling Change Day to happen, how the potential of social media was actively exploited at all levels and what else might be done in future. Section 3.10 Outcomes: A Special Kind of Grasstops Leadership focuses on what NHS Change Day tells us about the role of senior leaders in mobilisation efforts and the implications that this has for the kind of leadership that they may need to offer day-in day-out. Section 3.11 Outcomes: A ‘Dual Operating System’ extends learning about leadership into the kinds of formal and informal structures that were used by NHS Change Day and what this suggests about the value for the NHS of more intentionally operating through hierarchy and networks simultaneously. 9
  • 10. Stuart Sutton – GP, Becton Surgery, East London Core leadership team Originator of the first tweet with Helen Bevan Conclusion: Leaders Everywhere Recommendations Our conclusion is not only that NHS Change Day was an extraordinary event which created significant new capacity but also that it helped to model the development of distributed leadership that makes the most of the standardising potential of hierarchy and the relational potential of networks. We include twelve recommendations that draw on the learning from NHS Change Day 2012. These are intended as a contribution to NHS Change Day 2014 and to assist others around the world interested in applying a Change Day approach. 10 Leaders Everywhere The Story of NHS Change Day
  • 11. CHAPTER 1: THE NATIONAL STORY 1.1 A Time of Enormous Challenge Change Day occurred in a context in which the NHS was under great financial, organisational and reputational strain. Although the government had protected NHS funding, the service as a whole was looking to achieve £20bn in efficiency savings by 2015. At the same time, the 2011 Health and Social Care Act had ushered in a period of restructuring intended to shift resources towards primary care by giving responsibility for commissioning most services to Clinical Commissioning Groups led by GPs. Amidst these financial and structural challenges, NHS staff – like other public service employees – were facing the consequences of the government’s austerity programme in the form of an agreement to a twoyear pay freeze in order to avoid compulsory redundancies. Concern about patient safety and the standard of care provided the constant background to this period of challenge for the NHS with regular media coverage of perceived failings and shortcomings. The long-running series of inquiries into major failings at Mid-Staffordshire NHS Foundation Trust exemplified this concern and published a series of damning reports with wide-ranging recommendations.1 The inquiry was due to issue its final report in February 2013 – one month before NHS Change Day. This combination of factors created a climate in which NHS staff were under considerable internal pressure and frequently negative external scrutiny. In the midst of this reality, many cynics dismissed the Change Day effort. Some felt that “committing” to a pledge was another way for line managers to get people to comply with improvement measures by dressing it up as applying ‘social movement theory.’ Others argued, “It is already our job to improve the NHS; why should I treat this day differently from any other?” Still others worried that it was a politically charged effort 1 and wished to remain neutral. Some were too exhausted by their day jobs, admitting that they didn’t want one more thing to have to do. And others felt that the effort would not produce measurable impact, citing pledges as “insignificant.” These cynics watched from the sidelines as an explosion of energy and commitment from frontline staff created a different reality. Jackie Lynton from the NHS Change Day core leadership team stated: “At the end of it, onlookers shook their heads and asked ‘How on earth did this happen?’” It was as though NHS Change Day 2013 connected with a certain mood amongst those facing financial pressures, reorganisation and the imminent publication of the final Francis Report into the failings at Mid-Staffordshire NHS Foundation Trust. The timing suggests the importance of the ‘sense of urgency’ that surrounded NHS Change Day, as it provided an opportunity to transform people’s anger or frustration into constructive action. The British people undoubtedly have a special relationship with the NHS. In a recent national survey, people said they cherish the NHS more than the Royal Family or the armed forces (Katwala, NHS featured in the Olympics 2012 2013). Politician Nigel Lawson famously described the NHS as “the closest thing the English have to a national religion” (Katwala, 2011).” It is difficult to imagine any other country that The inquiry was led by Robert Francis QC, and the reports are referred to as ‘the Francis report.’ Leaders Everywhere The Story of NHS Change Day 11
  • 12. would, without irony, celebrate its health service in front of the world at the Opening Ceremony of the Olympic Games. NHS Change Day harnessed its people’s pride and passion for a system designed to take care of its own. The NHS is also the biggest health system in the world, serving the needs of a population of 54 million people.2 The sixth biggest employer in the world, only the U.S. Department of Defense, the People’s Liberation Army of China, Walmart, and McDonald’s have more people (Alexander, 2012). Everyday a million patients use the services of the NHS. It is a massive complex system – and as such, not easy to change. Yet NHS Change Day marked the single biggest improvement event in any organisation in the world. Why? Each and every one of its workforce of 1.7 million employees were treated as potential leaders of change. 1.2 The Birth of NHS Change Day The story begins in 2012 when a conversation began on Twitter between a GP and healthcare improvement thought leader. GP Stuart Sutton had just attended Helen Bevan’s talk on “Building Contagious Commitment to Change” as part of the learning programme run for Darzi Fellows by the King’s Fund. Helen had worked for years to apply social movement principles to improving health care, in part as a response to some existing change initiatives using Lean, Six Sigma and other industry approaches. Trained in community organizing methods, Helen encouraged others in the NHS to learn from leaders of great social movements, people who had few resources, no hierarchical and positional power, but who delivered results by building power through collective action. 1 12 During her presentation, Helen asked the audience to describe the projects that they were working on. 70 percent described cost-benefit efficiency projects; and 30 percent described projects focused on quality, patient care or the safety-experience. Helen then challenged her audience to consider how the design of projects generates commitment from others. Was anyone up for doing something differently? Helen’s provocation got Stuart thinking, and after the training he and Helen exchanged Tweets. They agreed to meet and talk more about what “mobilising young clinicians” across the NHS might look like. Paediatric trainee, Damian Roland, joined the conversation; and Helen encouraged Stuart and Damian to take seriously their passion to make a difference for patients. Even though emerging clinicians like Stuart and Damian might be perceived as powerless and at the bottom of the NHS hierarchy, Helen understood that young people historically drive change, and that effective leadership comes from within a constituency, not outside it. In fact, in 1948, it was the new generation of doctors who lived through the war that were instrumental in overthrowing the established order and securing the establishment of the NHS in the first place. Stuart and Damian recruited other emerging clinical leaders to explore ideas over the course of two conference calls. The make-up of this group reflected the engagement of Generation Y, who in previous years had been focused on completing their clinical training and kick-starting their careers. This growing cadre of younger leaders were active on social media, ready to engage in change, and passionate about making a difference for patients. The inquiry was led by Robert Francis QC, and the reports are referred to as ‘the Francis report.’ Leaders Everywhere The Story of NHS Change Day
  • 13. They ultimately took their inspiration for Change Day from Earth Hour, a worldwide event organized by the World Wide Fund for Nature (WWF), that encourages households and businesses to turn off their non-essential lights for more than one hour to raise awareness about the need for action on climate change. The first event took place at the end of March 2007, when 2.2 million residents of Sydney participated by turning off all non-essential lights. Following Sydney’s lead, many other cities around the world adopted the event. By 2012, it was taking place in more than 7000 cities and towns across 152 countries and territories. The emerging clinical leaders’ initial questions were about what the NHS could do that was equivalent to turning the lights off. They asked themselves, “What should we use as our goal? Should we identify a specific action that we want everyone to take, or should we leave it to people to take action that is meaningful to them? How will we measure outcomes? Who owns Change Day, and how do we allow it to be led – and remain led – by the grassroots?” The main difference between Earth Hour and NHS Change Day is that Earth Hour is an umbrella movement that brings many organisations and activists together in a common cause. NHS Change Day is a movement largely inside – and alongside – a hierarchical system. Jackie Lynton played a special leadership role in bringing this about. As Lead Associate for Thought Leadership & Change Model at the then-NHS Institute for Innovation and Improvement, Jackie sat in on an early conference call among the emerging clinical leaders. She immediately recognized their idea as a mobilisation project and saw its potential. Jackie established a strong coaching relationship with Damian, who initially wanted to give people a menu of two to three national pledges to choose from, in part motivated by a desire to measure impact. Leaders Everywhere The Story of NHS Change Day Based on her own experience as a former clinician, Jackie encouraged him to consider the power of “not telling people what to do” but of giving them the opportunity to decide for themselves. With her coaching, the emerging clinical leaders together decided it was critical to maintain a balance between igniting frontline engagement and using the leverage of the hierarchy to make positive change happen as a voluntary grassroots effort. They wanted to create “leaders everywhere.” Out of their initial leadership grew a core leadership team that recruited other members with particular technical and organisational expertise. The role of the core leadership team was to organise and mobilise people and put in place a range of channels, activities and platforms – particularly through relationships and social media – to enable individuals amongst the NHS and its supporters to join the effort. Members of the core team included: Damian Roland (Paediatric Senior Registrar), Stuart Sutton (GP), Pollyanna Jones (NHS Graduate Management Trainee), Kat Trimble (PR and Communications), Jacqui Fowler (Social Media and Knowledge Management), Joe McCrea (Social Media Strategy), and a team of improvement leaders from the NHS Institute including Helen Bevan, Rachel Douglas-Clark, Michaela Firth, Stuart Hill, Jackie Lynton, and Alan Nobbs. The ongoing coaching dynamic between the emerging clinical leaders and improvement leaders played an important role. The improvement leaders provoked the clinicians to take action, serve as role models, and act as spokespersons. Meanwhile the improvement leaders helped the clinicians develop leadership skills and a campaign structure. In turn, the clinicians provided leadership ‘from within’ the frontlines of the NHS. They provided the effort with real credibility among the clinical community. 13
  • 14. Over the course of the next few months, the core leadership team worked together in the following way: they had one half-day strategy session to agree to the goal, shared purpose and campaign plan; a weekly 1-hour WebEx meeting to agree to ongoing tactics and actions; hours of spontaneous coaching and support across the team; calls to action to keep their energy up and motivate each other; and support from an oversight group made up of senior leaders. Here is what they did with that. 1.3 From Zero to 189,000 Pledges The first challenge the team faced was to decide on a commitment-based goal. In other words, they could not create “leaders everywhere” through compliance; NHS Change day had to be underpinned by intrinsic motivation around shared values, one that anyone could commit to. Initially they thought of asking everyone to take part to develop an improvement project inspired by some of the best practices approaches that already existed. Some thought a target of 500 projects might be aspirational but reasonable. Others thought they could be more ambitious. At a strategy meeting, the goal of achieving 65,000 online pledges was agreed – 1,000 for every year of the NHS. This was a nerve-wracking choice. How would they secure that level of commitment? After brainstorming various ways in which this could be brought about, they developed the concept of a single day of action. They had six months to get there. This is the campaign chart that sets out the leadership team’s timeline for NHS Change Day and the “mountain top goal” of 65,000 pledges. 14 The next challenge point came in December. According to Alan Nobbs, the team was working furiously to answer strategic questions like “How do we get the message out? How do we filter it down? How do we help people focus on pledges that are important? How do we structure leadership, and how do we practice leadership? How do we enable others?” Stuart Hill adds, “We were also facing our own challenges and uncertainty. With the restructuring of the NHS, many of us faced redundancy and redeployment. I personally felt challenged in giving Change Day the energy it needed in the midst of all that noise.” Leaders Everywhere The Story of NHS Change Day
  • 15. Damian Roland agrees. “We did struggle in December. We were hugely behind schedule, we were revisiting the strategic direction, and challenging personality dynamics began to emerge within the team. Jackie Lynton, in particular, exercised leadership by renewing our relationships, shared purpose, and values to forge a new level of trust.” Jackie Lynton looked at her role as an improvement leader in a particular way. “I saw my role as fending off internal and external resistance to enable our young leaders to unleash their energy. It was about enabling them – and all the members of our team – to do what they were good at. It personified the whole effort. I was saying I am here to support you, I am here to enable you, I will deal with the rubbish. That is what our pledgemakers did too. Their pledges say the same thing to our patients.” The New Year was a New Year. January marked the public launch of NHS Change Day, and that in and of itself energized the team. Along with it was the public release of the NHS Change Day video and website. The team saw its own “story of us” personified in the urgent call to action brought alive on camera and online. Stuart Sutton pointed out, “The public launch was a breakthrough moment. We got our narrative right, we made the connection to people on the frontlines real, and the film was a brilliant recruitment tool. When I showed it to people, they got it!” After the launch of Change Day, the number of pledges started slowly rising. Although the core team had built a lot of relationships and asked many organisations and individuals to make pledges before or on the day itself, nothing could have prepared them for what happened. In the final month before 13 March, Change Day took off. Leaders Everywhere The Story of NHS Change Day The Francis Report was released on 6 February. It provided an urgent challenge to call people to action. Feedback and requests for support began to pour in from organisations and individuals. Social media channels began to build traction and traffic. On 14 February, the total was 5,000. By 21 February it had grown to 43,000, and by t March it stood at 80,169 – breaking the target with two weeks still to go. The 100,000-pledge mark was broken at lunchtime on Monday 11 March. By the morning of Change Day itself, there were 130,000 pledges registered on the website – double the target. Liz Saunders from the healthcare policy think tank, the King’s Fund, blogged and tweeted on the evening before NHS Change Day: “If ever you’re losing faith that there is the energy to make a difference in the NHS… there are more than 130,000 pledges on there, people actively choosing to make a difference to the services they provide and to patient care. It’s uplifting.” Change Day pledges poured into the online site throughout the day. The focus of NHS Change Day was England, but people caught the spirit in Ireland and made over 13,000 pledges from there. By the end of Change Day, 182,000 pledges had been received. Over 50,000 had come in on the day itself. A further 1,000 were added the day afterward, and a further 7,000 before the end of March – hitting a total of 189,000 pledges listed on the Pledge Wall. That does not account for those who did not list their pledge, which is estimated at over 300,000. 15
  • 16. The success of Change Day led well-known NHS commentator, Roy Lilley, to declare: “Sometimes an event comes along that simply and fundamentally changes things. They call it a ‘gamechanger.’ The dictionary definition is ‘a newly introduced element or factor that changes an existing situation or activity in a significant way.’ Well, I think we have a new Gamechanger. It’s called NHS Change Day. It happened this week, and it came from the NHS grassroots.” 1.4 Summary of Quantitative Research & Results What did the effort result in? What can be gleaned from the patterns within the pledges? • The most profound finding was that ‘it can be done.’ NHS staff can be mobilised to take action around shared values. Over 189,000 pledges were submitted to the NHS Change Day website, and this total was a fraction of the pledges made and carried out that day. As Joe McCrea, the Social Lead of the core leadership team, quipped, “This thing could have been a heroic failure in which case lots of the people who are now saying that they were always supporters would have been pillorying the core team!” • Since March, a quantitative analysis of the pledges was conducted. Survey research shows that the primary motivation for people to get involved in Change Day was to improve patient care, closely followed by “I wanted to make a difference,” and “I wanted to learn from others.” In contrast, the two least motivating factors to get involved in Change Day were “because I was told to” and “because I was asked to.” This finding demonstrates that intrinsic motivation around share values was critical to Change Day’s success, not strategies based on compulsion, compliance or exhortation. • 54 percent of pledges on the website involved action taken by a single individual; 71 percent involved fewer than nine people; and 94 percent involved fewer than 50 people. 16 Leaders Everywhere The Story of NHS Change Day
  • 17. • Overall, 25 percent of NHS organisations took part. NHS Trusts led the way, in addition to wide support received from NHS-aligned organisations and individuals. There is still room for improvement for engagement at CCGs and GP practices in particular, as only 5 percent of CCGs and 0.1 percent of GP practices were engaged (see left). • 68 percent of pledges focused on better patient care or spreading innovation. 10 percent targeted personal development; 10 percent on using services effective; 7 percent on celebrating services; and 5 percent on implementing integration (see left). • 36 pledges encompassed almost 3,500 people involved in simply ‘smiling’ with fellow patients or staff (see below). Leaders Everywhere The Story of NHS Change Day 17
  • 18. Victoria Stead, Receptionist, Becton Surgery, East London Other metrics and patterns have been summarized in “The Difference a Day Makes – Interim Report from NHS Change Day,” published in May 2013, “Biggest Ever Day of Collective Action to Improve Healthcare that Started with a Tweet” posted to the Management Innovation website in June 2013, and “What Did NHS Change Day Pledges Tell Us About What Matters to Staff and Patients?” submitted in June 2013. These publications also include metrics around the use of social media, a topic that is discussed in Chapter 3 of this report. 18 But what can we learn from pledge-makers themselves? This is where the spirit and soul of NHS Change Day was made real, where the action made a difference to patients and practices. The above-mentioned NHS Change Day publications describe many excellent and inspiring examples of pledges received. This report does not. Instead, it looks carefully at four different pledges and draws out the qualitative learning from pledge-makers. Leaders Everywhere The Story of NHS Change Day
  • 19. CHAPTER 2: THE PLEDGE-MAKERS’ STORY One version of the NHS Change Day story is what happened to initiate it and enable it to grow. This is the story that we told in Chapter 1. Another version of the story is about pledge-makers on the ground and how their actions made Change Day real to NHS staff and patients. In this chapter we look at four distinct pledges in detail to understand their stories and draw out the lessons they can teach us. These pledges come from (1) NHS Arden Commissioning Support, (2) Open Minds Alliance Community Interest Company, (3) Derbyshire Community Health Services Trust, and (4) Steve Fairman of NHS England. (Three additional pledge-makers’ stories are included in Appendices A-C; and we draw on some of their learning in Chapter 3.) Anna Burns, the Director of Strategy & Engagement at the NHS South Warwickshire CCG, explained: “Volunteers employed a four-step discussion with individual members of the public that drew on the importance of patient-feedback as outlined in the Francis Report. First, we told them, ‘Today is NHS Change Day. If you could make a change to your local NHS, what would it be?’ Then we asked, ‘How well do you feel the NHS listens to you?’ Next we used it as an opportunity to explain the restructuring of CCGs and how it would affect them. Last we recruited volunteers to serve as Health Champions. Everyone had a clipboard and discussion form for responses. We spent about twenty minutes with each person, and spoke with a total of 450 people.” Before exploring these examples, it is important to note that the “behind-thescenes” work of the leadership team was invisible to almost all pledgemakers. Most were exposed to the website, a video, possibly an email or a Tweet. Colleagues encouraged them by word-of-mouth to make a pledge. It appeared as an opportunity to many people to take an idea and make it real, to link existing local work to national purpose, or to step outside of habit and try something new – without asking anyone for permission. A logistics team coordinated with contacts at each local site, secured public liability insurance, staffed each site with volunteer coordinators, and provided the requisite materials to each volunteer. Although volunteers approached members of the public individually, they were assigned to subgroups of two or three in order to support one another. The leadership team recruited volunteers via email and personal asks and thanked everyone afterwards. 2.1 The Story of NHS Arden Commissioning Support Why this pledge: Rebecca Davidson, the Communications and Engagement Lead, explained their reasoning. “In response to the Francis Report, we translated our pledge as going into the community to ask what changes the public would like to see and how well the NHS listens to them and their concerns. Change Day was also happening during a huge time of change with the establishment of CCGs. It was a timely reminder to the public about the restructuring going on and how it affected them. And it was really important that we have a vibrant engagement programme, so we used the opportunity to recruit Health Champions. Those were the main drivers for us.” The pledge: Working with three local Clinical Commissioning Groups (CCGs) (NHS Coventry and Rugby CCG, NHS South Warwickshire CCG, and NHS Warwickshire North CCG), a team of over 50 NHS Commissioning Support Staff, lay people and patients formed a volunteerbased NHS Change Day team. They went into shopping centres, supermarkets, hospitals, GP surgeries and on the streets to ask people’s opinions about the NHS. The event took place from 9am to 7pm on 13 March at 17 different locations across Warwickshire and Coventry. Leaders Everywhere The Story of NHS Change Day 19
  • 20. How they got involved: Anna Burns explained: “Jackie Lynton (from the national NHS Change Day Team) asked us to consider getting involved. To be honest, NHS Change Day did not connect with us as an organisation in terms of making individual pledges. We are in a market town in a semirural area among a predominantly middle-aged white male group of GPs that are engaged in improvement, but not in this fashion. In addition, March is one of the worst months for us because of the timing of the commissioning process and the financial year starting on 1 April. If it hadn’t been for Jackie reaching out, I’m not sure we would have done it.” Outcomes: The NHS Change Day team communicated to the CCG Governing Body that they should devise more opportunities for people to offer feedback to the NHS on the services they have received. As Anna Burns captured in her formal report on NHS Change Day to the CCG Governing Body: “Face-to-face meetings are an important method of communication for people to raise concerns, and it is important that the feedback is recorded and acted upon. Work also needs to be done so that people know how to provide feedback, and to demonstrate that providing feedback makes a direct difference to improving services… It is essential for the CCG to engage with the public and patients to ensure that their views are fed into decision making and to ensure transparency.” In addition, the CCG’s pledge allowed them to identify and recruit over 100 local Health Champions. Health Champions are invited to participate in the CCG by (1) receiving regular news and updates about what is happening in South Warwickshire’s health care services; (2) taking part in surveys and consultations to influence the development of services and how the CCG spends its money; (3) attending events, health seminars and other patient and public involvement activities; and (4) engaging other local people, patients and carers across the area. One in four people 20 surveyed on NHS Change Day agreed to participate in this programme, which accounts for one in ten of the presently enrolled Health Champions in the area. Lessons: In the context of the pledge itself, the local team received direct feedback about how to improve confidence in the NHS: reducing waiting times; weekend opening hours for GP practices (and/or access to get an appointment should be improved); better communication, including more information available in different languages; a helpdesk available for when service goes wrong; less political involvement; better staff training; improvements in care; and doctors focusing more on care and less on finances. As for feedback to the NHS, 34 percent of respondents previously offered feedback about NHS services. Of those that provided feedback, most did so face-to-face, with letter being the second most popular method of feedback, email the third most popular, and phone the fourth. The majority of respondents preferred not to be anonymous in their feedback. There were a variety of reasons for not offering feedback, including: not knowing how to provide it; thinking it would be a ‘waste of time’ and not used or applied; being happy with the services and therefore no perceived need; or feeling decisions were already made. This taught the CCG that they should do more to let people know how to provide feedback and demonstrate it makes a direct difference to improving services. From a NHS Change Day perspective, the team felt the ‘urgency of the moment.’ Between the Francis Report and upcoming changes to CCGs, there were many reasons to engage the public more broadly. The team will use this learning to develop future pledges in the real and present context “of the ‘moment’” when future Change Days occur. Leaders Everywhere The Story of NHS Change Day
  • 21. Team members also valued forming relationships with the public face-toface, which also proved an effective strategy for recruiting a large number of Health Champions. Making personal connections allowed them to motivate members of the public to join the Health Champions programme. In turn, volunteers valued the opportunity to take on a public-facing role. Team leaders also built relationships with contacts from respective venues, and the CCG is likely to go back – or has already been back – to those places for further outreach. In addition, NHS Change Day provided an opportunity for senior leaders in the CCG (15 people) to work directly with GPs and registered nurses (22 people), as well as lay people and members of the public. As Directors, Anna Burns and Rebecca Davidson reported the benefit of spending time as a larger team and working toward a shared purpose. This kind of activity allowed them to build stronger relationships across hierarchical and organisational boundaries. Team members are now able to share ideas more readily and make better decisions together because they can call on shared experiences with one another that demonstrate their willingness to improve to the NHS. Changes in thinking and leading: Anna Burns reported, “Because people are not inclined to give feedback, when they do, the ability to offer that feedback face-to-face is a really important mechanism. That was our biggest take-home message. We use social media and websites for outreach, but what is important is to talk to patients and the public faceto-face. We need to make ourselves more accessible and talk to people. That really took me by surprise. To get feedback, we have to be visible, we have to ask for it. It helps us to see how others see us; and it helps them to feel heard by us. Putting a response form on a website is insufficient. People want to talk.” Leaders Everywhere The Story of NHS Change Day The team has subsequently run campaigns and involved volunteers in direct outreach with the public. They also use press releases, Twitter, websites and other social media to build capacity around programmes like Health Champions. They feel it is good to communicate more often and more effectively with the public, especially face-to-face, and to invite the public to offer direct impact on the kind of care the CCG provides. NHS Change Day approach: As Anna Burns reported, “Although we felt connected to the national effort, for us, this was a very local pledge. We tweeted a photo of our team at the market in Coventry to the wider NHS Change Day effort, but really this was about Change Day in Warwickshire and Coventry. Our people knew less about the national effort than they did about our local action. “Our particular CCG has 15 staff. We are always asking them to improve things, that is our job. Change Day feels a little bit like a false concept, because we should be continuously improving and finding solutions every day to benefit patients. As a team we role model this behaviour, we do not accept mediocrity, we expect things to be better. NHS Change Day is a useful reminder to all of us that we cannot become complacent in what we are doing. Organisations who feel competent fail. If we are reminded to improve – at improvement – we will continue to try harder. “I invited the GPs to join NHS Change Day and asked whether they wanted to do something in their own practices; no one wanted to do it. Some people feel differently [about this approach], and we have to accept those differences. Not that they don’t get engaged – they do in their own way! But we can’t make people ‘do’ things. We have to meet people where they are. They saw what we did. Next year they may feel that it is relevant to them. But it is not our job to impose it, just to encourage and support.” That is the spirit of Change Day. 21
  • 22. “We positioned our pledge to coincide with Change Day, but we were planning to do it anyway. We framed it that way among our CCGs and GP practices, so they knew that it was important to us, whether or not it was a part of Change Day. It was important to keep the pledge simple, to align it with what we were already doing. It had to be low-key, with a lowthreshold to be involved. We didn’t spend extra money on it, we asked people for 3-hours of their time. We used resources we already had. intervention from a colleague, friend, compassionate health provider or care giver could make a real difference to saving lives.” “We might look at Change Day through a different lens. The fact that people said that it was so motivating to feel empowered to take action on one day, that signals that the rest of the time they don’t. That is a much bigger problem for the NHS. NHS Change Day should be every day!” In order to support the pledge, each individual or organisation had to commit to take some specific action that would spread the message of the U Can Cope campaign and direct individuals to resources that could help them if they were troubled by suicidal thoughts. “We had to be sure that it was not just a paper exercise,” explains Alys Cole-King. In practice this meant that every supporting organisation had to communicate the U Can Cope message to their members, supporters or staff. 2.2 The Story of Open Minds Alliance Community Interest Company The pledge: “I pledge to share we can all get through distress and suicidal thoughts. There is always help/hope via U Can Cope” This pledge was posted on 8 March, one week before NHS Change Day, with thousands of actions taking place over the following weeks. The pledge was supported by a team led by Alys Cole King, a Consultant Liaison Psychiatrist, together with the Open Minds Alliance Community Interest Company, based in London and North Wales. Open Minds Alliance CIC was established in 2010 and provides suicide prevention training and resources aimed not just at medical professionals but society as a whole. As Alys Cole-King and Gavin Peake-Jones explain, “our belief is that emotional distress, and tragically, suicide still affects and takes far too many lives. We felt that responsibility for people with suicidal thoughts was seen to lie with specialist mental health services and others were more nervous to get involved. However we knew that early 22 From the outset the objective for Open Minds Alliance CIC was to secure as many supporters of the pledge as possible. The pledge was deliberately crafted so that it would appear in a single tweet – the aim being to secure as many re-tweets as possible. Why this pledge: For Open Minds Alliance CIC, participating in NHS Change Day was about much more than a publicity or marketing drive. Their approach to suicide prevention is built on a belief that it is possible to develop the protective factors of each individual and help them to gain knowledge and control over suicidal thoughts and impulses. Alys Cole-King describes this as, “a compassionate alternative to the so-called ‘management’ of suicide risk…it promotes a role for all, and recognizes that each encounter with an individual with suicidal thoughts is an opportunity to intervene and potentially save a life.” When she talks about promoting a role for all, she really does mean all: the resources made available by Open Minds Alliance CIC are intended to be used by everyone and anyone. How Open Minds Alliance CIC got involved: Alys Cole-King has been working collaboratively for many years on the issue of suicide prevention Leaders Everywhere The Story of NHS Change Day
  • 23. and has a wide range of national contacts. One of these contacts, Kath Evans, is Head of Patient Experience for NHS England and has worked closely with a number of the NHS Change Day Core Team. When Kath heard about NHS Change Day she immediately thought of Alys and the work of the Open Minds Alliance. Kath knew Alys and her colleagues were looking for a way to effectively engage the wider NHS and might be attracted by the possibilities offered by Change Day. So she got on the phone and invited Alys to make a pledge. Outcomes: The U Can Cope pledge secured over 58,000 supporters – more than any other single NHS Change Day pledge. As the Open Minds Alliance CIC team point out this is an especially remarkable achievement given the social stigma associated with suicide. “Change Day had an amplifying effect,” explains Gavin Peake-Jones. “It enabled us to get to a much wider range of people. It has been a catalyst to broaden thinking about suicide and has enabled us to have impact at all the different touch points. By breaking down stigma, people will get the support and resources that they need.” Open Minds Alliance CIC was notably successful in securing the support of a number of large organisations both inside and outside the NHS. These included The Royal College of Psychiatrists, The Professional Cricketer’s Association and The Rugby Player’s Association – all of whom committed to take action. In the case of the Betsi Cadwaladr Health Board, where Cole-King is Consultant Liaison Psychiatrist, this included handing out leaflets to staff and patients, two direct emails to all staff and coverage in internal newsletters. “It was absolutely unprecedented,” reflects Cole-King. Other supporters included the College of Emergency Medicine, which communicated the U Can Cope message to all its members via its newsletter and Twitter and Barnsley Metropolitan Borough Council which put a mailshot through every home in their locality. Leaders Everywhere The Story of NHS Change Day From their own research, Open Minds Alliance CIC knew that people who are in distress tend to be seen first in primary care and that there is a deficit of training and resources in that area. As a result of contacts made and supporters recruited through NHS Change Day, new work in this area has begun, for example in Dudley & Walsall where Open Minds Alliance CIC is working across mental health teams and their partners. The overall success of NHS Change Day has provided an additional and unexpected impact for the work of Open Minds Alliance’s partners. “Being part of Change Day provided a greater level of credibility for our work,” says Kirsty Thomson, Head of Fundraising at Awyr Las Gogledd Cymru – a funder and close partner of Open Minds Alliance CIC. “To be able to talk to future supporters and to speak to our bosses about the impact of the work – their ears pricked up when they heard it had been part of NHS Change Day.” Lessons: Open Minds Alliance CIC is located in North Wales and Alys Cole-King is based at Health Board within the Welsh NHS (not the English NHS). While Open Minds Alliance CIC works extensively with the NHS in England, the Welsh team’s distance from London is one reason why the advantages of being part of a single day of action stand out for the team. “The national platform brings a heightened level of awareness and provides a focus,” says Gavin Peake-Jones. “Change Day is something you can’t avoid.” According to Kirsty Thomson there was also value in participating alongside others: “Seeing that there is a national Change Day was inspiring. Understanding that it’s not just people on the periphery who want to make change happen but people throughout the NHS. There was a sense of solidarity – of not being on your own. Feeling part of something bigger is a really important factor.” 23
  • 24. NHS Change Day approach: Alongside the focus and solidarity created by a single day of action, the team at Open Minds Alliance CIC was also struck by the way in which Change Day gave permission for people to initiate and embed change. “The national day was symbolic – giving people the time and space to think about the change they would like to make.” universally adopted within the NHS. “I’m an enthusiastic user of Twitter,” says Alice Cole-King, “which led to raised eyebrows from some colleagues!” One of the successes of Change Day was that “it inspired people who may not normally engage in social media. It showed how it can enable individual nurses, physios – frontline staff – to collaborate.” In addition the structure of Change Day itself reflected a different approach to culture and organisational change that resonated strongly with the approach of Open Minds Alliance CIC: • “The way in which NHS Change Day was formulated – people identified issues for themselves and others could sign up or not – meant that it was self-selecting. What came up were the issues that mattered to people.” (Sian Peake-Jones) • “In the same breath as talking about the change we were also talking about being part of Change Day. It allows people to get on with things and breaks down barriers.” (Gavin Peake-Jones) In addition the team itself valued the changes in their own thinking prompted by their interactions with a whole new set of contacts as a result of Change Day: “We’ve had people asking us challenging questions and asking us to do things slightly differently. NHS Change Day has been a catalyst to broaden our thinking.” Although he now gives much of his time to Open Minds Alliance CIC, Gavin Peake-Jones has a professional background in organisational change having worked for the likes of Marks & Spencer and Ford as well as founding a successful social enterprise. He saw NHS Change Day as a rare example of a large organisation demonstrating that it understood the complexity of the change process “rather than seeing the organisation as a machine with inputs and outputs.” For Peake-Jones, “working with people at the grassroots to set strategy is critical.” This was one of the strengths of Change Day as it enabled a flow of ideas between the people who were pledging. In this way Change Day “created the right systems and processes to enable the change to take place.” It is perhaps not surprising that Open Minds Alliance CIC was able to make such good use of the opportunities of NHS Change Day. After all, as Gavin Peake-Jones says, “there is a campaigning quality to our work. We’re passionate about embedding change. We want to be that change. It’s not a routine job for any of us.” Or as Alys King-Cole concludes, “It’s also a very enjoyable activity. These are the things that motivate us when we go to work – making a difference for people.” Changes in thinking and leading: Open Minds Alliance CIC recognise that as innovators they have tended to work in ways that are not 24 Gavin Peake-Jones reflected that Change Day had the effect of generating new points of leadership in the NHS, of which Open Minds Alliance CIC was just one: “Change Day is a national initiative that gives us permission to initiate culture change.” 2.3 The Story of Derbyshire Community Health Services Trust The pledge: The staff of the Derbyshire Community Health Services (DCHS) Trust made a corporate pledge to “identify and support Innovation Scouts” through a local “NHS Change Week.” Individual and team pledges included pledges on Change Day and Change Week – and some are ongoing today. Leaders Everywhere The Story of NHS Change Day
  • 25. The corporate energy for the pledge came from the Service Improvement team who secured a Board commitment to support a Change Week to coincide with Change Day. Led by Ian Murray (Head of Service Improvement & Innovation), Donna Clemens and Helen Short (Service Improvement Managers), the Service Improvement team communicated directly with the 200 voluntary Innovation Scouts asking them to make personal pledges for NHS Change Day and to recruit others in their part of the organisation to do the same: “the Improvement Leadership Training they had all taken was voluntary so we already knew they were passionate and engaged about improvement and creative thinking. We knew most of them would say ‘yes’ – and they did!” “We wanted to make sure that most people knew about Change Day,” explained one team member. “So we put together a PR campaign which included email invitations to all staff to join in Change Day and Change Week. The ‘comms’ team was great! We had a 10-day count down with daily emails including the Change Day branding asking ‘what are you going to do to make a difference?’ and we highlighted the pledges that the Chief Exec and other members of the Exec Team were making.” As part of the PR strategy the Service Improvement team developed a ‘menu’ of pledges which they encouraged staff to adapt, adopt or use as a prompt for their own thinking. The Service Improvement team was keen to ensure that Change Day and Change Week fast-forwarded change in a sustainable way. They launched the ‘My Idea’ email address as part of the Change Day/Change Week campaign and most of the DCHS pledges were made using this route. This meant that all the pledges came through to a single point in the Service Improvement team: “It was important to understand who was making pledges and where they were in the organisation. It meant that we were able to provide support and enable corporate pick-up where appropriate.” Leaders Everywhere The Story of NHS Change Day The team created a local ‘pledge wall’ and all the DCHS pledges were uploaded to the national NHS Change Day website. One Innovation Scout on each of the Trust’s sites volunteered to raise awareness of Change Day and to promote it amongst teams. During Change Week they were asked to make themselves as visible as possible to encourage people to make pledges. Why this pledge: DCHS has taken a proactive approach to supporting innovation for a number of years. A survey identified that staff often didn’t know where to go or what to do with their ideas for innovation and change. DCHS therefore developed an innovation infrastructure which included identifying volunteer Innovation Scouts who were provided with Improvement Leadership Training. Innovation Scouts came from all parts and levels of the Trust and so could act as “the eyes and ears of the organisation… if staff came up with an idea they would be the first point of call.” The Service Improvement team had aspirations to go further. They wanted to make it as easy as possible for members of staff to share their ideas and get the support they needed to make them a reality. The Service Improvement team therefore planned to launch a dedicated ‘My idea’ email address with a commitment that each email would receive a response within three days including a short plan setting out the support they could provide. Change Day “seemed like an ideal catalyst and was a driver to publicise and fast-track some of the things that we were already thinking about. We brought things forward because Change Day created a deadline. We thought ‘let’s get it done for Change Week’ so that we can promote a full end-to-end model that people can have confidence in.” 25
  • 26. How DCHS got involved: Members of the Service Improvement team responded to early adverts for NHS Change Day and brought it back to the team and organisation. The team saw NHS Change Day as an “exciting opportunity to motivate and engage staff in innovation and change.” In particular the team viewed NHS Change Day as a way to “mobilise and motivate” the 200 Innovation Scouts already developed within DCHS and to “to get them to influence harder to reach groups.” Outcomes: In total over 500 teams and individuals made over 150 different pledges: “Big themes appeared around talking and listening more; with patients and with staff. Seeing things from different angles and perspectives to ensure we are managing our staff in the best way and delivering care in the way our patients want. This has lead us to having a drop-in at our AGM where we will be asking patients about the best way to communicate…what they think about our services which isn’t necessarily a complaint or a compliment, this could simply be small things they think could make a difference.” The Harlem Shake: DCHS Healthy Work Champions in the Health Records Team at St Oswald’s Community Hospital pledged ”to be active in our workplace as part of our health and wellbeing.” During Change Week they ran a range of drop-in activity sessions for staff which ranged from yoga to Nordic walking. To promote this pledge and encourage participation in the sessions they made a video of themselves doing the Harlem Shake which they posted and which became a local sensation with over 2000 hits. Not only did this help to bring 100 people to the sessions it also helped to create a buzz around Change Day in DCHS. “All in all this was definitely worth doing and worth all our hard work and effort, and from the feedback we have received from staff they all really enjoyed it, and were very grateful to us for giving them the opportunity to get 26 involved, look at new things, and really take a look at themselves (which we don’t very often have time to do),” Nicola Shaw, Medical Secretary. Podiatry Services: Danny Connor, Podiatry Manager, pledged “to obtain patient questions via video and play at team meetings to discuss feedback and communications to patients/service users” as a way of enabling patients “to tell their own story, in their own words, in their own way.” Staff reported that sharing the experience of patients in this way “brought patients into the room… ensuring that patients remain at the heart of what we do.” As a direct result of video shot during NHS Change Week there have been improvements in signage, patient information and notification. The team now embraces this way of capturing the patient experience: video items have become a regular feature of agendas and videos are shown quarterly at team meetings. Video replies from the Podiatry Manager responding to patients’ ideas, observations and questions are also provided “to present a ‘face’ to the public (as opposed to the faceless management!)” There are now plans to roll out this approach to capturing patient experience across DCHS. DCHS is also looking at other ways to develop this pledge such as filming staff with questions for governors and managers to be discussed at leadership and staff forums. The ongoing impact of Change Day can still be felt at DCHS: “We’ve got initiatives that have happened and are continuing as a result of Change Day. It allowed a bigger footprint of opportunity within the organisation to have permission to make a difference. It allowed people to channel ideas through a framework. Before, they might have been lost or forgotten before they had been able to grow. People now know where to go for support and we can help nurture them.” Leaders Everywhere The Story of NHS Change Day
  • 27. The Service Improvement team have been continuing to support many of the Change Day pledges through their ‘Let’s Keep it Going’ programme. This has included visiting teams and individuals who made pledges to discuss sustainability and to identify barriers and blockages. Change Day has become part of the improvement and innovation landscape at DCHS: “We keep talking about Change Day and feature it in our Trust comms flyer to celebrate what we’ve achieved. The Chief Exec mentions it in emails. The scene is being set for next year!” Lessons: “The amount of effort that went into putting an effective PR campaign together beforehand. We are a big organisation with over 4500 staff. Getting the message over in as many different ways as possible was fundamental to making sure that people got involved. “We needed to make it as easy as possible for people to pledge – e.g. having the menu of pledges to sow the seeds which really increased take up. “When we first heard about Change Day we thought it was a brilliant idea but in some parts of the organisation there was a kind of ‘so what’ concern asking ‘what does it do for longer-term change and improvement and change at scale?’ So we had to think about how we could make sure that it wasn’t just one day without any measurable impact. Having the pledges channelled locally meant they could be followed up after Change Day and in some cases developed from local to corporate pledges. “Where there is something a bit different you start with the people who are most committed and then you get some momentum which brings the uncommitted and then even the most resistant.” Changes in thinking and leading: “We seem to be coming out of a culture where we’ve found we’ve had to overtly give permission for staff to make a difference. In our Improvement Leadership Programme we say ‘if you need it this is the permission to make a difference’ and people say ‘oh, right, OK. We didn’t know we could do that.’ NHS Change Day did that too. “For the NHS, Change Day was a little bit different. To bring it into the NHS had some foresight. But it was simple – it didn’t require complex mobilisation; you could think about your pledge on the day and then carry it out. You can make a simple pledge that will make a difference to a single patient or a cohort of patients. “Pledges were made where you think ‘we should be doing that anyway’ but in a lot of cases we don’t. It helped to bring you back to basics. “It influenced the approach of managers and showed them the skill and creativity they have in their teams. It demonstrated that people at the front of their teams know their business better than others e.g. the managerial support for the Healthy Working initiatives – I don’t think that would have happened before.” “It remained entirely voluntary – the spirit about it is wanting to make a team or an individual difference. I truly believe that for service improvement one volunteer is better than 10 pressed men. Leaders Everywhere The Story of NHS Change Day 27
  • 28. 2.4 The Story of Steve Fairman, NHS England The pledge: Steve Fairman, the Director of Business, Improvement and Research for NHS England, pledged to spend a day shadowing a GP, James Gray, in Sheffield; and he asked James for a reciprocal pledge to shadow Steve for a day. Steve spent a day in June with over 100 patients who came into contact with members of James Gray’s general practice team. Throughout the day, Steve shadowed two receptionists, a GP responsible for telephone triage, a GP conducting home visits, and a GP doing in-patient surgery. He also shadowed the practice manager. “I saw all ends of the spectrum in a single day.” GP James Gray and practice manager Joanne Marshall now plan to shadow Steve for a day. “I don’t want to make it easy for them; they are going to get the nitty-gritty. They will be here when I have corporate decision-making work. They are going to see that I spend a lot of time video-conferencing because I can’t be in two places at once, and that is what a national job demands. It is a very different way of working than on the frontlines.” Outcomes: “People have asked me: What was the point of my day in Sheffield? What has changed as a result? For me, my attitude has changed. But I can’t show you that on a graph or a run chart. It will manifest its impact because other people hear what I say or because I develop a relationship in a different way or because I argue a point more persuasively by drawing on my experience. Some people need numbers to understand change. I started my career in information management, and I appreciate the numbers. But I’ve moved on from that. “I lead a lot of leadership development programmes for the NHS, and my pledge has armed me with real life examples. I used to put up PowerPoint slides with data and evidence and walk through them. Now I put up the same slides and call on my experiences with GPs and patients to illustrate why a particular idea is important… Why this pledge: Although Steve had been aware of NHS Change Day for months, he had not committed to a pledge that was meaningful to him until a few weeks before Change Day. “Over the years as my career developed I got further and further from patients. I wanted to do something that would engage me with the patients and also provide a reciprocal lens for someone else to see what it was like at my end of the NHS.” “For instance, when I put up a slide that says ‘patient expectations are rising,’ I can tell the story of Mr. Jones. James and I visited Mr. Jones at his home and found him lying on a sofa in the corner of the room watching television. Mr. Jones did not greet James as his doctor but instead jabbed his finger at the television and asked James whether he watches Embarrassing Bodies (the TV show). James said no. Mr. Jones said, ‘Well, I have exactly what the guy on last week’s show had, and I know exactly what needs to be done about it.’ I saw how Mr. Jones’ expectations affected his encounter with James, their relationship and the care he received. I realised how hard the work of the GP is in dealing with those kinds of expectations before an exam has been completed. How Steve got involved: Steve was first exposed to NHS Change Day through his work with Helen Bevan on the Change Model and was a part of the NHS Change Day Expert Oversight Group. “I also tell people about Mr. Smith. While I was sitting with another GP between surgery appointments, the phone rang from reception. ‘Mr. Smith is here, can you see him?’ The GP said yes, send him in. Mr. Smith did not have 28 Leaders Everywhere The Story of NHS Change Day
  • 29. an appointment. He was in his early 80s and had dementia. The practice agreed that they would care for him even when he turned up on the wrong day to see his doctors. They agreed that whoever had space would find time to see him. They also agreed with Mr. Smith’s daughter that they would write any instructions for care on a brightly coloured card and put it in his top pocket. She agreed that she would look for the cards and follow the instructions. On this day, Mr. Smith needed long socks and cream for a sore on his leg. I tell this story to demonstrate what a dementia-friendly practice looks like.” I am involved in a piece of work to identify research priorities from clinical groups across the country, and I have asked two GPs from Sheffield to take part because I want their views to be heard. They believe they can do things in primary care that are currently being done in secondary care. Initial studies suggest that they are right. Lessons: “I was surprised at how profound an impact my pledge had on me. I didn’t expect to learn many of the things that I encountered. For example, I learned about the – sometimes directly conflicting – incentives of ownership in GP practices. GPs are partners in small businesses. They all have a vote, and unless they all agree to something within their group, the practice as a whole cannot change. “I now seek out this kind of thing. For example, I work with a graduate trainee. Usually she comes to my office, and we discuss issues pertaining to where she works, the people she works with. I decided to take the train to London to visit her at her hospital. Now I understand who her people are and what her building looks like, and I can empathize when she tells a story. It is important – not only to her training, but to the outcome of our relationship – that I made this effort to understand her experience.” This [approach] has potential to create a significant, even if not always intentional, blockage to improvement.... There is a tension in having the incentives of small businesses play such an important role in the NHS. If we want to improve, we have to change the incentive structures.” Changes in thinking and leading: In his day job, Steve is responsible for developing transformational healthcare change programmes at a national level. He has a varied background extending from academic social research to health economics to demographic forecasting. He is also responsible for helping develop a better evidence base to inform future NHS-wide decisions. In Steve’s words: “Now that I know more about what happens at the frontlines, I ask myself: ‘What are the gaps in knowledge that frontline practitioners would find helpful if they could commission research on it?’ Leaders Everywhere The Story of NHS Change Day “My team needs to bring this kind of credibility to our work. It comes from understanding what people at the front lines are doing and the issues they are facing. NHS Change Day approach: “Change Day is a very important part of the NHS. If we all have tools for change in our tool bags, as it were, Change Day is a very important tool. It’s not a tool that everyone will want to use. I asked my own team to make pledges, and not all of them did. I understand; it’s not how most people in the NHS think change happens. I have many traditionalthinking people on my team. Change Day is not their thing. They would rather do some lean thinking down the corridor. But Change Day is about doing something differently. It’s not an expert telling you the best way to change; it’s not a consultant working with you to create change. It’s about people seeing things from their standpoint and saying: ‘I am going to change that’. 29
  • 30. Whizz Kidds featured on NHS Change Day at Healthcare Expo “I was so pleased that it came from the bottom up way of thinking about change. Change Day empowers individuals in the NHS – and there are an awful lot of them – to make change happen, no matter who you are. Look, if half a million NHS staff commit to Change Day 2014, they are making a powerful statement that the NHS needs to change. Half a million people can spread the word about Change Day to everyone they go home to. One of the potential sources of Change Day’s power is that it is building a base for change. 30 “I have noticed that the reports about Change Day highlight numbers: how many people did this, how many Tweets, how many pledges, how many organisations, how many chief executives. Are they responding to the critics who want to see measurement, metrics, impact? I don’t know. But it leaves out the bigger lesson that we can learn from Change Day. It is about leadership.” Leaders Everywhere The Story of NHS Change Day
  • 31. CHAPTER 3: LEARNING FROM NHS CHANGE DAY 2013 3.1 ‘Impact’ or ‘Design & Outcomes’? There is considerable debate about the ‘impact’ of NHS Change Day. There are those who have been decidedly sceptical arguing that without firm data showing the link between Change Day and an improvement in patient care or specific cost saving, it is not possible to call Change Day a success. It is certainly true that while there are many examples of specific improvements detailed in this report and associated case studies, NHS Change Day 2013 was not designed in a way that would allow measurement against traditional improvement metrics. The appropriate place for traditional improvements metrics to emerge within Change Day is at the level of pledge-makers, and it is thereby a voluntary activity – as part of a pledge. Those involved in the design of NHS Change Day 2013 do not shy away from this criticism and readily admit that “if you want evidence of direct patient change that is sustained I suspect there is not a lot” (Damian Roland). This very issue was debated among the core leadership early on, and they intentionally pursued a strategy that gives people the option to choose the nature of their pledge, instead of signing onto one or two specific pledges that would take on the quality of a national campaign (and measured more traditionally). Thus the number of pledges alone is not so much evidence of change but the impact of reach in using social media. The Change Day leadership team sees the emphasis on pledging – instead of acting on a pledge – as an area for improvement. “It is one thing to pledge, it is another in terms of what difference it made,”points out Helen Bevan. “We don’t have conversion rates. What percentage of pledges made converted to 3 action? When you talk to people in the voluntary sector, they have a conversion rate for pledge-based campaigns. The fact that so many people pledged was important, but we have to understand a lot more about what impact it had for patients and the system as a whole.” The core team has been examining the patterns in the 2013 pledges in order to develop metrics for 2014. They recognize that many more elements of Change Day can be measured, such as impact measures from pledges or on the effects of pledges on involved patients and staff. For example, since many pledges in 2013 suggested that participation arose from a commitment to the values of the NHS, and that involvement was intrinsically motivating, Change Day 2014 could assess whether Change Day contributes to motivating staff in their jobs. It might also be helpful to measure the impact of pledges on organisations in the system. For example, Hertfordshire Community Health Service Trust used Change Day as an opportunity to bring together clinicians from across their system to review the paperwork that they are required to complete, resulting in significant changes to the entire reporting system. In addition, Change Day 2014 can track the conversion rate of pledges into actions.3 Beyond impact measures, developing metrics that reflect the unique character of NHS Change Day is both possible and desirable: NHS Change Day 2014 can embrace its unique design by quantifying how it works. For instance, it is important to count how many pledges came from frontline staff and patients, as well as senior leaders as an indicator of the effect on distributed leadership. The NHS Change Day team already has plans to make it easy for people to pledge and report what happened. Pledge-makers will get a text message that reads: ‘Did you do it? How did it go? What happened as a result?’ Leaders Everywhere The Story of NHS Change Day 31
  • 32. Core leadership team members on NHS Change Day Measuring how many people told an online or on-the-ground narrative to mobilise others as part of their pledge would provide evidence of the level of new capacity developed through NHS Change Day. Similarly, counting how many new relationships were built through Change Day is an important indicator of success. Quantifying the design elements of the Change Day approach helps tells the story of how it enables distributed leadership, commitment, and boundarycrossing relationships to innovate around patient care – and contribute to other ongoing organisational challenges. 32 Measuring the impact of specific pledges – and collecting evidence around the outcomes of the Change Day design – cannot be understated. But despite the prevailing culture of evidence-based activity in the NHS, an absence of impact measures is not in itself an indication of the success or failure of NHS Change Day 2013. Change Day did not set out to be a traditional improvement programme. On the contrary, it was deliberately designed to be something new; a movement of people within the NHS motivated by shared values and a commitment to the possibility of change and improvement. As one leading participant puts it: “For this sort of thing I think it would be counterproductive to try to measure the direct impact of the interventions” (James Haddow). Another adds: “The greatest success Leaders Everywhere The Story of NHS Change Day
  • 33. we had was getting people involved in something that just wouldn’t have been possible a decade ago, five years ago – maybe even two years ago” (Damian Roland). 3.2 Design: NHS Change Day, Social Movements and Hierarchy frontlines to take action while at the same time engaging hierarchical leaders. In their own words the NHS core team sought to make “the best of both networks and hierarchies, working through informal networks and communities of interest and creating a genuine grassroots movement at the same time as enabling leaders with positional authority to role model ‘change leadership’ in a new way” (NHS Improving Quality, 2013). As Jackie Lynton puts it: “It was important to work with the hierarchy at an early stage. I sought the support of Jane Cummings, Bruce Keogh, David Nicholson and Miles Ayling, who were all massive supporters but respected the grassroots nature of Change Day.” NHS Change Day did not emerge from nowhere. For over ten years a number of leaders in the NHS have been laying the groundwork for the development of a social movement principles to improving health care. This included engaging with and adapting insights from social movement theory and research, developing skills used in community organising and developing a ‘Call to Action’ framework used to mobilise action on critical challenges (Bate, Bevan and Robert, 2006; NHS Institute for Innovation and Improvement, 2011). This activity led to success but on a small scale; the next challenge was to deliver change across a whole system. The innovative design of Change Day resulted in a particular set of outcomes (as opposed to metrics) that we consider in this chapter. We explore outcomes that resulted from design elements including a distributed leadership model, an emphasis on building relationships, taking voluntary action, mobilisation around shared values, collective action, social media, support from the ‘grasstops,’ and networks. We consider the strengths, challenges and limitations that emerged and opportunities for development in the future. The design of NHS Change Day inevitably shaped outcomes that were achieved. In this chapter we look at that design and consider the range of outcomes that flowed from it, the challenges and limitations that emerged and opportunities for development in the future. Yet by no means did all the members of the Change Day core team participate in this prior activity. Having recently completed the intense years of clinical training, emerging leaders like Stuart and Damian were entering practice, dissatisfied by what they found. They had an appetite for learning from leaders of great social movements, people who had few resources, and no hierarchical or positional power, but delivered results by building power through collective action. While learning from social movements, these change agents within the NHS also engaged creatively with the hierarchical structures in which they operate. The design of NHS Change Day is unique precisely because it is a social movement approach that is consciously empowering people at the Leaders Everywhere The Story of NHS Change Day 3.3 Outcomes: Distributed Leadership Distributed leadership is already a familiar concept in public, private and voluntary organisations. There is no single definition, but it is broadly taken to describe leadership as something that arises from the behaviours and actions of an individual anywhere in an organisation rather than something associated with a position in a hierarchy. Structures of distributed leadership aim to create many ‘leaders’ throughout an organisation who are capable of taking action on their own initiative while welcoming a high level of personal accountability (Northouse, 2013: 289; Wise, Woods and Harvey, 2003: 7-9). Social movements, which rely entirely on the voluntary commitment and resources of their supporters, exhibit many of the characteristics of distributed leadership. 33
  • 34. Comparison of hierarchy leadership model and interdependent leadership model Traditional Structure The structures and process of the NHS, with its clear hierarchies and culture of targets and top-down accountability, is clearly a very different kind of an organisation. Indeed, it is striking how often those we have interviewed have commented on the extent to which their NHS colleagues feel that they need to have ‘permission’ before they can change something or make an improvement. Having observed this pattern of behaviour among staff, Jackie Lynton commissioned a cartoon for Change Day that captures the prevailing culture of staff seeking permission to take action: Distributed leadership 34 Leaders Everywhere The Story of NHS Change Day
  • 35. NHS Change Day was explicitly designed to challenge this culture and to create opportunities for people throughout the NHS to take action without having to ask for permission. with your patients? It might be really effective but unlikely that you’d be given the time in regular day to day. Where do you get time to think that stuff up? Change Day created that opportunity.” This design was reflected in the decision not to have a single pledge that everyone would be asked to adopt. “One of the core values of the NHS Change Day was inclusivity and empowerment of the frontline rather than imposing or dictating what people on the frontline should do…[we wanted it to be] an empowering experience based on social movement theory where people would be connected through their core values. You can’t do that if you tell people what their core values should be” (James Haddow). Instead, a group from the frontline got together to make something happen and invited others to contribute their own ideas and energy to the collective effort. This design principle was echoed in the approach taken by a number of pledge-makers. The teams in Birmingham City Hospital (see Appendix B) and Derbyshire Community Health Services (DCHS) (see Section 2.3) were aiming to mobilise colleagues across their organisations. Both teams considered and rejected the idea of pursuing a single pledge precisely because they wanted to stay true to the spirit of NHS Change Day. As a result, DCHS generated over 150 different pledges from 500 teams and individuals. This design principle had one very specific outcome: it created space for the individual motivations and insights of NHS staff to be expressed through a rich variety of pledges. As Damian Roland puts it, “there were no rules – it was simply ‘make a pledge’.” Each Change Day pledge reflected an individual’s priority for change responding to his/her own local context and personal gifts and motivations. This would not have happened if Change Day had been designed differently. As Liz Saunders, then at the King’s Fund and now at the Hay Group, reflected, “NHS Change Day gave permission for people to go where their passion is. In the NHS we often look for change to a particularly end, for example to reduce waiting lists or improve a particular pathway. This doesn’t tend to lead us to the unexpected, or things that might improve patient experience. What about baking cakes Leaders Everywhere The Story of NHS Change Day For some pledge-makers the central objective of NHS Change Day – with its emphasis on mobilizing a movement for change across the NHS based on the belief that everyone has a contribution to make – was itself a motivation for getting involved. This approach mirrored the values and beliefs of Open Minds Alliance and the U Can Cope campaign perfectly (see Section 2.2). “We were attracted by the fact that this was a grassroots initiative,” explains Gavin Peake-Jones. “People at the front line doing one thing together.” Ironically, some staff may have seen NHS Change Day itself as providing a kind of hierarchical authority – but one that offered agency to them. Alys Cole King, Consultant Liaison Psychiatrist at the Betsi Cadwaladr University Health Board, observed, “People in the frontline can think that they can’t change anything. People wouldn’t have had the confidence but because it’s part of Change Day it sort of gave them permission.” 35
  • 36. Challenges of distributed leadership Applying distributed leadership was not without its challenges. Within the core team, which actively tried to model distributed leadership, this was sometimes felt acutely. “The concept of distributed leadership was new to me,” explains Damian Roland. “But it wouldn’t have worked if we had said ‘this person is in charge.’…Sometimes it was messy, especially around decision-making; but our trust got us through it.” As members of the core team readily admit, there were times when they reverted to more closed leadership styles – and that was when they ran into trouble. Finding the most effective way of ensuring a constant flow of information through the core team and out to key activists was a particular challenge: “We couldn’t always tell what the core leadership team was doing… It was very difficult to engage with them, to push out the messages and to get others engaged at the right time” (Pollyanna Jones). Creating a structure for distributed leadership early on can help when challenges arise (as they inevitably will). Core team members readily admit that beyond their central team, they failed to develop other distributed leadership structures to support Change Day engagement across England. For Change Day 2014 there are already efforts to develop a geographic nodal distributed leadership structure, so that leadership moves from one central Change Day team to many teams across the country working to engage their networks. This reflects the determination of the NHS Change Day team to continue to learn and to model the behaviours that they are encouraging others to demonstrate in order to develop greater capacity for action. By taking this approach, they are offering a kind of leadership often seen in social movements: enabling others to exercise leadership to achieve shared purpose (Ganz, 2010: 509). 36 3.4 Outcomes: Building Relationships Social movements rely on the strength of the relationships between their members for their effectiveness. Relationships build movements and sustain them when they face difficulty or defeat; it is through relationships that new members are recruited; and it is because of relationships that new resources are made available. This is why community organisers and other social activists put so much time into learning and teaching relationship building (Ganz, 2010: 514-515). Social media played such a central role in enabling the growth of NHS Change Day that it can obscure the offline relationships that underpinned the whole effort. In fact, the importance of relationships to NHS Change Day can be seen in every stage of its development. Beginning NHS Change Day has its roots in relationships between people like Helen Bevan and Stuart Sutton, and Jackie Lynton and Damian Roland. It wasn’t just that each saw something in the other that inspired them; it was also that each one had resources that the other lacked. Through their relationship new resources were made available for shared action. As they began to explore taking action together, Stuart and Damian brought in other emerging clinical leaders; Helen recruited Jackie and other improvement leaders; and so it went on. Old relationships were deepened and new relationships were forged. As Jackie Lynton puts it, “It started with a belief in each other…It is using each other and how we’ve been able to capture each other’s energy. Some of us didn’t even know each other before we started!” Leaders Everywhere The Story of NHS Change Day
  • 37. The nature of relationships in social movements (Marshall Ganz) Sustaining Not surprisingly getting NHS Change Day off the ground was not without it’s difficult moments. At these points the investment in building relationships paid off: “We built trust on our team by building relationships around our shared values” (Damian Roland). Recruiting The early growth of NHS Change Day was based on relationship building. As Alan Nobbs recalls, “I remember sitting in a meeting in a grand room in a grand restaurant with Stuart Hill and Stuart Sutton and saying that it was not enough to send emails, we have to build one-to-one relationships and connect to shared values. Stuart Sutton said that until we talk to people, nothing will happen. Once we moved from the theoretical to the actual – that is when we got some momentum.” This momentum included directly recruiting colleagues from around the country to take a lead, make a pledge and recruit others to join them. Pledge-makers Ellie Milner and Harry Giles had this experience at Birmingham Children’s Hospital (BCH) (see Appendix B). As Patient Experience and Health Promotion Workers, their day jobs took them in and out of the wards; and both had good relationships across the hospital. “When they were doing their ward visits they would talk to the ward managers about Change Day – and talk them into taking the posters and the pledge slips,” explains Janette Vyse the Patient Experience Lead at BCH. “Ellie’s personal experience fires her passion and Harry is very bubbly as well – that really helped!” Eventually the relationship building hit a critical point and NHS Change really began to take off. “What heartened me,” recalls Liz Saunders, “was when I Leaders Everywhere The Story of NHS Change Day 37
  • 38. got a call from a manager in Cornwall who had got the NHS Change Day video but not through me. It became clear that nobody had control of Change Day anymore. It felt a bit dangerous but in a good way!” Relationship-building not only enabled NHS Change Day, it was one of its design principles. As a result, a host of outcomes were achieved that would not have been possible with a less deliberately relational approach. Michaela Firth, one of the members of the Core Team, identified new relationships as one of the most significant outcomes of NHS Change Day: “The core team built relationships with one another, and now we use those relationships as a resource. There is an immediate group of people that we can go to for direct support because we have a shared feeling of what we did together. I now call on at least 35 people that I didn’t before.” This was far from an isolated experience. As Joe McCrea puts it, “We provoked conversations and relationships between different groups of people in different parts of the NHS that will make lots of little changes that will build up to a big change.” Some of the outcomes from this relational approach are intangible, but no less valuable for that. Liz Saunders reflected that, “Change Day gives us some of what we need. The benefits that people get from being in community with one another are huge – to have that network. We get so much from just being with each other.” Because it was designed to be relational, NHS Change Day developed new social capital – and capacity. This took the form of new relationships which not only have an intrinsic value for the people involved and a wider benefit for the NHS, they also provide the new resources on which NHS Change Day 2014 can draw. 38 3.5 Outcome: Weak Ties & Strong Ties NHS Change Day was in part sparked by the opportunity for individuals from different parts of the NHS to connect with colleagues with whom they might never have normally come into contact. This included, in particular, emerging clinicians, managers and improvement leaders. From the outset, therefore, NHS Change Day was able to draw on what Mark Granovetter famously called “the strength of weak ties” – in other words, the connections between people who are in some important way different from one another (Granovetter, 1973). This difference provided heterogeneity that ensured that new resources, insights, knowledge and – very importantly – contacts and networks could be combined. For instance, the presence of individuals on the core team, who worked at senior levels in the Department of Health, provided both important insights and opportunities to secure support and engagement. Equally important, the experience of practicing clinicians ensured that NHS Change Day remained constantly in touch with the experience of frontline staff. ‘Strong ties’ are what Granovetter calls the connections formed between people who have some fundamental similarity (Granovetter, 1973). In the NHS these might include the common bonds that exist within professional groups (such as ‘doctors,’ ‘nurses,’ ‘managers’). While these can build a powerful sense of identity, they can also limit the capacity of initiatives like Change Day to grow. If Change Day had been launched by a homogeneous core team, its capacity for growth would have been significantly limited. Leaders Everywhere The Story of NHS Change Day
  • 39. Comparison of strong ties network and weak ties network NHS Change Day created what one member of the core team called ‘thousands upon thousands of weak ties at the operational level.’ This is an important insight and signals the potential role of the relationships created through NHS Change Day in stimulating ongoing change long after the day itself has passed. As the core team member went on to explain: “Our job is to put in place a platform and tools where we do nothing, but which enables other people to do it for themselves. That will enable change that we won’t even know is happening. We will provoke conversations and relationships between different groups of people in different parts of the NHS that will make lots of little changes that will build up to a big change” (Joe McCrea). 3.6 Outcomes: Voluntary Action No one has to join a social movement, and they can leave whenever they want to. They are by their very nature voluntary. While many NHS staff regularly give much more to their jobs than their contracts require, they are nevertheless employed to do a specific job. Moreover, the long history of targets in the NHS and the more recent experience of reorganisation has created an environment in which many are understandable suspicious of yet another initiative being foisted on them. It is not surprising then that some people’s initial response when they heard about NHS Change Day was to ask, “what are ‘they’ doing now?” The answer, of course, was that ‘they’ were not doing anything. The voluntary nature of Change Day changed both the way in which pledge-makers were recruited, and the way in which they in turn could recruit others. Janette Vyse of Birmingham Children’s Hospital explained that it was a very different experience asking people to volunteer on the basis of commitment rather than trying to get them to agree because they Leaders Everywhere The Story of NHS Change Day 39
  • 40. were being required to participate: “We were honestly able to say ‘we would love you to!’” For Ian Murray of Derbyshire Community Services Trust (see Section 2.3), the voluntary nature of Change Day was crucial to its success: “It remained entirely voluntary – the spirit about it is wanting to make a team or an individual difference. I truly believe that for service improvement one volunteer is better than ten pressed men.” If the voluntary design principle changed the nature of the engagement from individuals and teams, it also changed the experience of bringing about change in the NHS. As Liz Saunders remembers, “There is a feeling that making change in the NHS is arduous. Here it didn’t feel like that… There was a sense of fun about it. It felt like it had a serious intent but was approached in a lighthearted way.” Joe McCrea similarly remarked, “By a country mile it is the most enjoyable, challenging, exciting, innovative, ground-breaking thing that I’ve been involved in in ten years. My wife says, ‘I’ve not seen you bound out of bed at five o’clock in the morning because you’ve had an idea and want to go and talk to somebody… It’s taken ten years off you.’ It’s renewed my enthusiasm!” Helen Bevan concludes, “It was the best example of volunteerism in the NHS. We never cracked it on volunteerism before… hierarchy trumped volunteerism. This time young leaders came because they were motivated, enthusiastic, and positive.” 3.7 Outcomes: Mobilisation around Shared Values Social movements draw together people who share a sense that change is needed – often urgently. In the face of an intolerable condition, action is 40 required. Joan Saddler, formerly the National Director of Patient and Public Affairs at the Department of Health, points out that the Change Day approach was atypical: “Usually you’ll get the Save Our Hospital campaigns which will have thousands of people coming out. But to do something from the stance, ‘we love the NHS, this is already a great service, how can we improve it?’ I thought it was spot on.” In other words, Change Day was designed to mobilise action for continuous improvement (positive) – not opposition to change (negative). The sense that ‘we love the NHS’ permeated the whole of NHS Change Day. Indeed, it is an expression of the shared values on which Change Day was built. As Stuart Sutton explains, “In the spirit of volunteerism, we wanted to give people the opportunity to connect to why they chose to be in the NHS... There is something more about working for the NHS. The NHS belongs to all of us – people who work in the NHS use the same services that our patients use. We all have ownership in the NHS.” This focus on shared values led the NHS Core Team to spend time developing their ability to communicate their values more effectively using narrative and story. Much to his surprise, Damian Roland found this a personally transformative experience that made a major contribution to the success of NHS Change Day: “The single most important skill I learned from improvement leaders was narrative. If I heard myself saying this a few years ago, I would be laughing at myself. I used to think that people standing up and telling ‘stories’ was ‘business babble’ basically and you don’t really need it – you just need to get on and do things. But one of the fundamental successes of Change Day was that our personal stories – why we all made our pledge, or the reasons we were called to work for the NHS – connected and motivated people. I am now a passionate believer in narrative. It will stay with me the rest of my career.” Leaders Everywhere The Story of NHS Change Day
  • 41. Pollyanna Jones heard Damian using his newly developed narrative skills, crafting a ‘call to action’ around a challenge, choice and outcome: “Damian’s Call to Action is why I got involved. That’s why I trusted that he would do a really good job and why I wanted to help out. It connected with my values. That shared value and belief in the NHS.” Public narrative – Self , Us and Now (Marshall Ganz) 3.8 Outcomes: Collective Action Social movements rarely call for their supporters to take action alone. Being based on shared values, social movements are an expression of a common identity and therefore naturally lend themselves to shared action. But collective action also has practical advantages. Working towards a single event or goal has the effect of galvanising activity and focusing minds; it provides something to aim for and an opportunity to celebrate once it has be achieved. By designing action around a single day, NHS Change Day was able to take advantage of all of these outcomes. Gavin Peake-Jones of Open Minds Alliance (see Section 2.2) appreciated the galvanising effect of working towards 13 March 2013: “The national day was symbolic – giving people the time and space to think about the change they would like to make.” For James Rowland, NHS Change Day was reminiscent of Comic Relief: “People who participate in Comic Relief all feel part of one cause even though they are split across geography and social class – that one day they all come together and feel part of it. That feeling of being part of something bigger was something I experienced. Knowing that several thousand other people also doing it.” Organising for action Putting shared values at the heart of Change Day provided an authentic ‘call to action’ to which others with a similar outlook responded. It made Change Day not only an opportunity to do something that would be of benefit to others, but also to express support for the institution of the NHS and the shared values that it represents. Leaders Everywhere The Story of NHS Change Day 41
  • 42. Mobilising collective action develops feelings of ‘YCMAD’ – i.e. ‘you can make a difference’ – feelings that motivate people to exercise leadership again in the future. It creates natural opportunities for leadership development that feed a virtuous cycle. “The majority of people wouldn’t call it ‘leadership,’” remarked one pledge-maker, “but each pledge is a leadership opportunity. So even if people think ‘I am not a leader, they are still exercising leadership by making good on their pledge.” Or as another pledge-maker put it, “If you’ve got five other people on your pledge, they are all involved in a shared purpose – you have them on board toward a single goal. That is what the NHS Change Model is. So when you come out the other end, you managed to join a movement of collective action, and maybe even lead some people yourself through a shared purpose – and you may not even realise that’s what you’ve done!” For some pledge-makers Twitter was integral to both the design and success of their action. Alys Cole-King, Consultant Liaison Psychiatrist at the Betsi Cadwaladr Health Board and founder of the Open Minds Alliance, used NHS Change Day as a way of growing support for the U Can Cope suicide reduction campaign (see Section 2.2). The pledge was deliberately crafted so that it would appear in a single tweet – the aim being to secure as many re-tweets as possible. Having posted the pledge on 8 March, one week before Change Day, Alys Cole-King drew on her wide network of contacts and Twitter followers to begin to recruit supporters. “We actively used social media,” explains Sian Peak-Jones (Open Minds Alliance Operations Director). “We used Alys almost as a brand and deliberately tried to develop her Twitter following.” Cole-King’s pledge ultimately achieved 58,000 supporters – more than any other NHS Change Day pledge. 3.9 Outcomes: Use of Social Media4 Events of recent years have demonstrated the powerful use that social movements can make of social media. The ability for people to connect, exchange ideas, support each other and ultimately mobilise has been illustrated in all parts of the world and in a wide range of circumstances. However, NHS Change Day may well be one of a few examples where social media has been used by employees to self-organise – not in protest but in order to take positive action. Twitter was a social media tool perfectly suited to both the needs and the spirit of NHS Change Day. It’s somewhat anarchic, unregulated and democratic culture mirrored the kind leadership and action that the Change Day Core Team were hoping to stimulate. As one closer observer noted, ”Twitter helped! No space to publish guidelines. It’s just a space for ideas” (Liz Saunders). Twitter Not only was NHS Change Day born out of a Twitter conversation, but Twitter went on to play a critical role in the growing and sustaining the work. The Change Day twitter feed ultimately reached over 12 million twitter impressions. 4 42 Lynton and McCrea, 2013. Leaders Everywhere The Story of NHS Change Day
  • 43. programme, thereby going from touching 450 people in face-to-face encounters to thousands of people across the area. Each tool has its place; and the key is knowing to use which approach, and for what end goal. YouTube The NHS Change Day Core Team and pledge-makers throughout the NHS made fantastically creative use of the YouTube. A YouTube channel was established that both broadcast videos created centrally and acted as a central point for sharing material created on the ground. In just 20 days before 13 March the channel built an audience of over 3,000 views for over 25 videos. The most popular YouTube video (1,272 views) was a Change Day jingle written and performed by staff at Harrogate Hospital, which reportedly had staff dancing in the corridors when it was broadcast on hospital radio. If Twitter played a major role in the success of NHS Change Day, it also had its limitations as a communication tool: “cascading information through Twitter was not enough” reflects Pollyanna Jones from the NHS Change Day core team. As the South Warwickshire CCG Change Day team discovered during their pledge, Twitter, websites and online surveys cannot replace the understanding that comes from face-to-face relationship building (see Section 2.1). For them, one key takeaway from their pledge was that there is no substitute for building relationships with people like Health Champions. Yet at the same time, like the national Change Day core team, the South Warwickshire CCG team employed Twitter, video clips, local press, and a website to generate awareness of their pledge and Health Champion Leaders Everywhere The Story of NHS Change Day In one case the making of a video was itself used as a tactic for building local support. The team in St. Oswald’s Hospital in Derbyshire made a pledge to ‘get staff more active in the workplace’ and decided to video themselves doing the Harlem Shuffle (see Section 2.3). The filming date was advertised on the staff discussion forum to encourage other staff across the organisation to join in on the latest internet craze and make a pledge too. When it was posted on the Internet the film generated over 2000 hits. Web The NHS Change Day website on which pledges were posted and supporters logged was built with very few resources using the existing systems that were available. As a result it was far from perfect and was frequently mentioned as one thing that the core team and other 43
  • 44. participants would want to change in the future: “It was not what we needed and I think we could have engaged many more people if we had had what we needed. I fielded so much criticism from my colleagues about the website… and I was quite frankly embarrassed about that” (Damian Roland). Nevertheless, the website did make it possible for people from across the NHS to communicate with each other around specific pledges. Its value should not be underestimated as a means of building connections, a sense of shared purpose and solidarity. For Joan Saddler, currently Associate Director at the NHS Confederation, this was a significant outcome of the whole Change Day experience: “You had a range of people popping up on your screen who would say ‘I’ve seen your pledge – it’s fantastic!’ They’d just be coming out of the woodwork and say, ‘really liked that, really well done.’ It made connections in that very simple way – and I met people through Change Day that I would never have met otherwise. “It also created a network of people who were part of a public NHS secret…’ I was part of Change Day – you were too, weren’t you!’” Ultimately, with all its flaws, the NHS Change Day web presence was the way in which the growth of Change Day could be observed. This provided a practical way of measuring success and, just as importantly, it created moments of hope and celebration. “When we started to see the pledges coming in thick and fast in the week running up to NHS Change Day, and then when we smashed our target, I didn’t need to hope any more because we’d already done it!” (James Haddow). There are plans in place to ensure that NHS Change Day 2014 has a stronger online and social media presence, including a seamless web, mobile and social media strategy. As Joe McCrea observes, “Let’s not try 44 to do loads and loads of different things and lose the focus. Let’s make it bigger and better and easier for Change Day to do what it did brilliantly the first time around.” 3.10 Outcomes: A Special Kind of Grasstops Leadership Change Day may have been led by the grassroots, but it was a unifying force that unearthed the convergence of shared purpose across senior NHS leaders and policymakers, and local managers and front line staff. Many senior leaders made personal pledges to Change Day. For example, David Nicholson pledged: “I will do the education and training associated with becoming a ‘Dementia Friend’ so that I can in my own working life, and in my life outside of work, make a contribution to improving the life expectancy and services that people with dementia receive… I also pledge that as NHS Commissioning Board Chief Executive, I will do everything I can to ensure that more and more people who work within the commissioning board make the dementia pledge. It is very important that everyone who is a part of the NHS Commissioning Board make a pledge as part of NHS Change Day.” This is an important design element to a “leaders everywhere” model. “[Senior leaders] of course should engage with [Change Day] like anyone else. They should in fact create the conditions that allow it to happen. But if a Chief Executive starts saying, ‘We’ll do NHS Change Day, but only if I see X pledges come from this group of staff, or from this organisation,’ then they are corrupting it” (Liz Saunders). There is unquestionably an important role for senior leaders to play in a mobilisation like Change Day, but it is not necessarily the role that many are used to playing. This message to senior leaders came in part from the core leadership team. They did not seek permission from senior leadership to run or Leaders Everywhere The Story of NHS Change Day
  • 45. launch Change Day. They decided collectively to do it and used what resources they could find. For instance, they needed a web platform to host the online “Pledge Wall” for people to post their pledges for action. They identified an existing website that they could adapt. It was not ideal because there was a complex registration system required for pledge-makers to access the system; and as a result a large number of pledges were not posted. But it worked well enough and taught the team what resources would be helpful in the future. In the end it was more important to build the spirit of volunteerism than to seek formal resources from line management. In well-organised change efforts, “resources get attracted, not allocated.” The core leadership team’s example modelled (both to the grassroots and to senior leaders) the role that senior leaders were expected to play – the same one as everyone else. One lesson for senior leaders comes from Helen Bevan’s example. She agitated and stimulated action from emerging clinical leaders of the NHS like Damian Roland and Stuart Sutton. She had the courage and humility to appreciate that their ideas might be groundbreaking. Without her effort to provoke the conversation and the energy around it, NHS Change Day might not have been born. She viewed the entire workforce of 1.7 million people as potential leaders of change, rather than those with positional power. She and her team of improvement leaders also provided cover to young leaders so they could be ‘enabled’ to take Change Day forward. This models the importance of allowing others to take the lead, and to use authority to protect innovative experiments like Change Day. As Joe McCrea reflected, “There were certain very senior people without whom Leaders Everywhere The Story of NHS Change Day Change Day would not have had its initial success. People like Miles Ayling ‘got’ the idea and were prepared to back it and say ‘give it a go.’ At the end of the day there was a huge investment in certain pledges. To have a huge presence at the centre of the Health Expo was also extraordinary. “It was a big leap of faith from some very senior people. If this thing had fallen on its face it would have left them feeling very embarrassed for having offered their support. That should not be underestimated.” In other words, senior leaders acted as signal generators to the NHS leadership community. Once they did so, many others started to pledge personally and to encourage their workforce to pledge. These senior leaders accepted the reduced control that comes with grassroots mobilisation. This does not always come easy to those in positions of hierarchical authority, who are used to directing and controlling projects. The Change Day model demonstrated that giving power away is what makes you powerful – together. Senior leaders can thereby help shape and inspire others. One example of this comes from Flo Panel-Coates, Director of Nursing at Barking, Havering and Redbridge University Hospitals NHS Trust (see Appendix A). “Every Thursday I have a clinical day. That involves my going into departments to talk to patients and staff, ask them about their experience, what frustrates them. Some patients were very critical of not having hot meals in the evenings. I have become a champion of bringing hot meals back in wards for patients. It’s not just listening; it’s doing something about what you hear. A colleague of mine, Jackie, has led our work on this, but she needed some support. She is a Director of 45
  • 46. Facilities, and I am a Director of Nursing, and it would have been hard for Jackie to champion that change on her own, though she is a formidable lady. She needed someone else to reflect the views of patients; it was easier to have someone to do it with together. We used NHS Change Day to springboard pieces of work like this.” This kind of modelling contributes to a shift in culture. Emma James, a member of the Communications Team at the Barking, Havering and Redbridge University Hospitals NHS Trust (see Appendix A), remarked, “I’m junior in the NHS, and I have found it to be very hierarchical. But I was most impressed with the executive leadership exercised around Change Day. We had some lovely directors who said ‘you are just as important as me.’ Having that feed through the organisation – Change Day helped us get the ball rolling to get a shift in culture – we are all in it together, it’s not just about those at the top. I want that to be felt throughout the entire organisation.” Flo agrees. “It is our job as an executive team to create the type of environment that encourages people to do the right thing by our patients. We have to work to change the culture in the NHS. We tell people we want them to be innovative. We are constrained by doing things the way we’ve always done them.” In other words, Change Day helped people step outside of daily habit and behaviours. “Our job is to get people to see things and do things different, and the freedom to do that. We don’t have the ideas and solutions; that comes from our staff. We have to give them safety to act and not shoot down their ideas. We often hold people back; we want to keep people safe to make their own mistakes and try things and fail and succeed!” 46 To support this kind of environment, senior leaders and managers have a vital role to play in modelling the behaviours they hope others will take. When Jonathan Griffiths, a Member of Governing Body of Vale Royal Clinical Commissioning Group (see Appendix C), read NHS Change Day tweets and reviewed its website, its model of distributed leadership appealed to him. He liked that anyone could commit to being a part of something larger than themselves, connecting their local action to a national community with shared values. Jonathan committed to spending the day in a wheelchair in order to appreciate, promote and raise awareness about the experiences of wheelchair users and International Wheelchair Day. Jonathan did not make a big deal of it, and he didn’t ask other people to join him or NHS Change Day. He believes in leading from example. “This is how I wish to lead. It’s not for other people. It’s what I believe in; this is me being me.” Change Day afforded him the opportunity “to put himself out there a little bit.” These actions can trigger other things. Even if for some it is a morale boosting day, it is worth our spending time to figure out ways to better appreciate and enjoy the work we are doing.” Some leaders have commented that Change Day could capitalise more on the involvement of big names, big leaders in the NHS - but not as a means of seeking permission. It wouldn’t be about ‘XX leader has endorsed this,’ but more that senior leaders would be making pledges to the effort, saying ‘this has to be done, and it doesn’t need to be down a formal route.’ Leaders and managers can explore the things that are happening as a result of Change Day and talk about them, raise up good examples of innovation and patient care. Although coming from the ‘bottom up,’ the ‘grasstops’ nonetheless carry some influence that can support the grassroots. Leaders Everywhere The Story of NHS Change Day
  • 47. In turn, however, is a worry from the grassroots that the effort is being co-opted or corrupted by senior leaders and managers. Even on the core leadership team, there was disagreement about the involvement of senior leaders, stemming from concern that it could be confused and misinterpreted. The authenticity of Change Day is about the ‘bottom up,’ and there was worry that ‘people at the grassroots will turn away from the involvement of people at the top.’ The risk of perception of senior ‘stamps of approval’ was argued to be counterproductive to the authenticity of the event. Others argued that it was “both-and.” As Helen Bevan remarked, “The NHS system needs to change massively. We need to educate our senior leaders to develop a distributed leadership approach. It is great for them to learn to do things differently, for them to show that they can act from their hearts as well as their heads. In every Call to Action we’ve engaged the existing system and hierarchy as well as the grassroots. In Change Day 2013 some of the best activities were where whole organisations got engaged, like the hospital system in Bristol. What they saw was that their leaders were leading change in a different way. We will only have a great NHS system in the future if the grassroots can engage and enable senior leaders and managers to be a different kind of leader. Change Day offers that opportunity.” This sentiment is shared at the highest levels of leadership. NHS England is working to increase and develop their citizen voice. Since Change Day, they invited Jackie Lynton to be part of the Design Team and Helen Bevan to the Design Day to help them with their thinking. They said, “You’ve done it. What can we learn from Change Day?” Core team leaders were invited to serve as facilitators to help the Department of Health with The Francis Report road shows to look at leadership and promote positive practice in a different way. That is the kind of Leaders Everywhere The Story of NHS Change Day leadership capacity being built from Change Day – not only at the grassroots, but at the grasstops – and it is a transformative complement to hierarchy. 3.11 Outcomes: A ‘Dual Operating System’ Along these lines, Change Day reflects a network-building approach that John Kotter calls a ‘dual operating system’ – in which a hierarchical structure sits alongside a ‘network’ built on volunteerism, enthusiasm and commitment (Kotter, 2012: 6-8). This second ‘operating system’ is devoted to the implementation of strategies that grow out of networklike structures. These networks are able to assess and respond to rapidly-changing and complex constraints and opportunities with greater speed and creativity than a traditional hierarchy, thus freeing both systems to do what they are optimized to do. This second system accelerates strategic change. Kotter suggests that there are five principles at the heart of this kind of dual operating system (Kotter, 2012: 7): 1. Many change agents, not just the usual few appointees 2. A want-to and a get-to – not just have-to – mindset 3. Head and heart, not just head 4. Much more leadership, not just more management 5. Two systems, one organisation Change Day reflects all five of these principles in practice. It invites many people into strategic change-making. It asks people to commit because they want to, not because they have to – thereby building a volunteer army that is focused, committed and passionate. It draws on stories and examples that appeal to people’s values and emotions, as opposed to simply appealing to the logic of metrics and measurement. It asks 47
  • 48. “everyone to be a leader,” encouraging all pledge-makers to contribute their unique vision, opportunities, agility, action and celebration. It treats its network and the hierarchy as inseparable, with a constant flow of activity between them – which functions because the volunteers in the network all work within the hierarchy. Although a typical hierarchy tends not to change from year to year, the network “operating system” can adapt with ease. The second annual Change Day will look different than the first; the tenth annual will look different than the second. Pledge-makers will develop pledges to new constraints and opportunities; improvements will build on improvements and organisational change. The hierarchy can learn from Change Day, as its pledge-makers communicate where there is urgency to affect change within the organisation. As Steve Fairman from NHS England (see Section 2.4) reflected, “I sit in a national job. My colleagues and I know the NHS has to change fundamentally in the next few years and offer a different type of service. What is the role of Change Day in that? We need to pay attention to what people who pledge to Change Day are saying and doing. We need to link their small actions to the larger agenda around change in the NHS. They are communicating powerful messages about what would make the NHS better.” Steve continued, “To start with, the NHS more widely could learn a lot from how the leadership of Change Day happened – it showed that a completely different type of leadership from the front lines can lead to something massive and important. It doesn’t need to have programme plans and risk registers and business assurance reports. They are not what is critical. What is critical is people’s commitment. How you get that commitment was modelled by those who led Change Day. I have nothing but admiration for those young people.” 48 Margery Shippen, volunteer at Leeds St James’s Hospital, made this pledge: "I pledge to smile at every patient I meet and greet… As a volunteer in the meet and greet service, making patients feel at ease is my role." Leaders Everywhere The Story of NHS Change Day
  • 49. CONCLUSION: LEADERS EVERYWHERE One of the most significant lessons raised by NHS Change Day is about what it means to have “leaders everywhere.” NHS Change Day shows us that it is possible to engage the grassroots, middle managers, and ‘grasstops’ – each in particular ways – to contribute to the improvement of the National Health Service together. Both the anarchic and authentic spirit of “forget the rules – let’s just try it” and the collaborative and inclusive attitude of “leaders everywhere” exist hand-in-hand in Change Day. But it is only through striking the delicate balance of frontline staff going for it, and senior leaders backing away from controlling it, that Change Day – and other efforts like it – will thrive. Learning to strike this balance is an urgent priority not only for Change Day 2014 and the NHS as a whole, but also for healthcare systems worldwide. It reflects the tension that exists between the necessary role of hierarchy and its significant limitations. Hierarchy, and the bureaucracy that goes with it, can be highly effective at delivering standardised processes and pathways, incremental improvement based on ‘best practice’ or technical expertise and, at its best, reliably high performance based on effective management and accountability systems. In situations where the challenges being addressed are ‘simple’ (e.g. compliance activity) or ‘complicated’ (e.g. heart surgery) hierarchical decision-making can be not only necessary but the safest and most effective structure. However, when the challenges being faced are ‘complex’ – as is the case with most of the challenges currently facing the NHS – a reliance on hierarchical decision-making can be self-defeating (Snowden and Bone, 2007: 3-5). While excellent in many ways, traditional NHS hierarchies can be too slow and too cumbersome to respond flexibly to difference, to the pace of change, to the appetite for innovation and change from both patients and frontline staff. In practice an organisation like the NHS needs what John Kotter has called the ‘dual operating system’ in which hierarchical structures sit alongside Leaders Everywhere The Story of NHS Change Day ‘networks’ based on volunteerism, enthusiasm and commitment. These networks give organisational form to the impetus for change that exists throughout an organisation like the NHS, but which can so easily be stifled. The exercise of authority drawn from formal hierarchy (based on holding a particular role or job title) or informal hierarchy (based on professional rivalries, gender, age) will undermine the shared purpose needed to make these networks successful. As John Kotter points out, creating a ‘dual operating system’ requires considerable willingness to learn (Kotter, 2012: 12) – and in this regard NHS Change Day 2013 offers a significant opportunity. Drawing on social movement theory and the practice of community organising, NHS Change Day deploys skills, behaviours and structures which – if amplified further – can give life to motivated networks capable of taking action across the NHS. Skills • Developing the capacity to use narrative as a tool for motivating others to join you in action. • Developing relational skills to enable the continual recruitment of new volunteers and the deepening of commitment of those already recruited. Behaviours • Developing a shared purpose based on shared values to provide the motivating vision for a team. • Practising interdependence based on clear roles, mutual accountability and intentionally strengthened relationships within a team. Structures • Distributed leadership structures based on interdependence and accountability rather than hierarchy. • Enabling strategy to be developed at multiple points within the system rather than driven from the top or centre. 49
  • 50. An effort like Change Day resulted in traditional evidence-based impacts across all pledges, but its design builds commitment, relationships, motivation, leadership and – ultimately – power to achieve better patient outcomes throughout the NHS. As a whole, Change Day empowers action by cultivating a safe and celebratory space for people to step outside of their everyday lenses, habits and behaviours to look at something differently, to appreciate a patient or colleague with greater empathy, or to try something in a new way. It galvanises people to focus on goodwill and taking action, and it creates urgency to do it. It is fun. And it allows people to feel a part of something bigger than themselves, to see that together their actions can assert influence over the system as a whole. Nas Kadeem, Adult Safe Guarding Leader at Tameside Hospital, made this pledge: " I pledge to smile a 50 people within my work place on NHS Change Day." There is no question that some will find it challenging and perhaps threatening to operate both interdependently within a network and hierarchically within a formal organisational structure; this way of working is certainly not for everyone. However, failure to embrace the value and possibility of networks of this kind will do nothing to reduce the challenges facing the NHS and could do a great deal to make them worse. As NHS Change Day has shown, enabling both operating systems to flourish requires the active participation of leaders at all points – from the grasstops to the grassroots. 50 To that end, it is important that the leadership framed the Change Day call to action and its underpinning narrative as about commitment, not compliance. In speaking with pledge-makers, we also discovered that the more relational the pledge, the more profound the experience for the pledge-maker – both in terms of immediate and ongoing impact. Yet the level of commitment is for a pledge-maker to decide; and the high degree of personal decision-making over the nature of a specific voluntary action is what enabled so many people to participate in the first place. This created the necessary conditions for hundreds of thousands of individuals to step forward and exercise leadership by making a pledge, and in many cases mobilizing others to do the same. Beyond all this, what final lesson might similar efforts learn from NHS Change Day? Simply put, social movement theory can be applied in many different health care settings. Look no further than the breadth of pledges, geographies, types of individuals and organisations that took part in NHS Change Day 2013 for national and local models of distributed leadership. We are grateful for all that they teach us, and we encourage us all to be a part of Change Day 2014 – in England and around the world. Leaders Everywhere The Story of NHS Change Day
  • 51. RECOMMENDATIONS Engaging with existing NHS processes: NHS Change Day was successful in part because it engaged with – but was not owned by – the hierarchy. There is a likelihood that the success of Change Day 2013 will attract the support of senior leaders keen to be associated with Change Day 2014. While this support may bring resources, it may also bring the constraints that come with being part of any formal hierarchy and thereby undermine the voluntary and networked relationships that were at the heart of Change Day 2013. For these reasons we recommend that NHS Change Day 2014 remain outside the formal NHS communication, improvement, training and management structures. This means signing up for ongoing tension and uncertainty, as well as the commitment and enthusiasm that volunteerism brings. These teams could be based on geography, professional groups, particular pledges or necessary functions (e.g. technical support). Their roles should be clearly defined, and the core team should in part be drawn from them. We recommend that the teams that make up the leadership of NHS Change Day 2014 are structured interdependently. Senior Leaders: Senior leaders have a critical role to play in the success of NHS Change Day 2014, most especially by acting as role models. We strongly encourage them to pledge, to choose something that reflects their values, and to find ways of sharing this story with others. We recommend that senior leaders resist the temptation to manage Change Day 2014 or mandate participation, and instead take the opportunity to model the value of enabling others to lead, using their positional authority to hold up the successes and stories of pledge-makers – and to demonstrate how senior leaders are learning from them. Emerging leaders: As with many social movements, NHS Change Day 2013 drew much of its initial impetus from the passion and commitment of grassroots staff. Younger members of staff may have fewer preconceptions about how things have traditionally been done and may be less invested in existing hierarchical structures – making them particularly attracted to a ‘networked’ way of working. They may also be more naturally familiar with social media. While NHS Change Day as a whole should seek to mobilise across generations, we recommend that the growth strategy for NHS Change Day 2014 includes a focus on identifying, recruiting and training emerging leaders from all parts of the NHS and beyond. Structure: In one sense NHS Change Day 2013 was highly centralised; it relied heavily on the leadership of a core team. This created significant pressures on a small group of people, reduced the potential strategic capacity of the core team and limited the ability to provide on-the-ground support and training to pledge-makers. We recommend that Change Day 2014 develops a more intentional structure of distributed leadership that allows teams throughout the country to take responsibility for particular aspects of the overall strategy. Leaders Everywhere The Story of NHS Change Day Skills and capacity: By participating in NHS Change Day 2013, many people in the NHS developed new skills – in narrative, building relationships, campaign management, social media, communications, and beyond. We recommend that planning for NHS Change Day 2014 includes creating opportunities for them to be passed on to others through trainings, webinars, online skills sharing, printed and online resources, and more. Patients, their families and citizens: NHS Change Day 2013 was sparked by NHS employees, and pledge-makers were overwhelmingly drawn from NHS staff. Building on this success, we recommend that the NHS Change Day 2014 strategy targets ways for patients, their families and citizens in general to contribute to the overall effort. Their involvement would amplify the values that underpin the NHS, and which 51
  • 52. are shared by the public. It would also help to blur the boundaries between ‘patient’ and ‘staff,’ reinforcing the sense that the ‘NHS belongs to us all’ and that ‘we share responsibility’ for improving and safeguarding it. Along those lines, NHS staff can be encouraged to recruit family members (children, parents) to make pledges. To ensure patient engagement, patients should also participate in the core leadership team. Integrate online and offline strategies: Much of NHS Change Day 2013’s success was the result of online activity, especially Twitter and the online pledge wall, as well as alerts that enabled a community to develop amongst pledge-makers and their supporters. Change Day action, of course, takes place off-line. There is now considerable experience amongst campaigning organisations of how best to integrate online and offline strategies. This is often described as a three-step process that is constantly repeated during the life of a campaign: 1. Engage people online: secure commitments/pledges, provide online resources, enable supporters to build community with others. 2. Take action offline: recruit others, follow through on pledges, record using video/photos. 3. Bring people back online: track progress, gather data and feedback, post video/photos, share stories and make the next commitment/pledge. This process could assist not only with securing action during Change Day itself but also building support in the run-up to Change Day. We therefore recommend that NHS Change Day 2014 includes an online/offline strategy that continues draws inspiration from contemporary campaigns and social movements. 52 Build on successes: There were a number of pledge-makers who were particularly successful at mobilising others, often within a specific organisation (e.g. Birmingham Children’s Hospital; Barking, Havering and Redbridge University Hospitals NHS Trust; and Derbyshire Community Health Care Trust). Many of these have the capacity to grow considerably in future. We recommend that NHS Change Day 2014 intentionally seek to build on these notable successes by providing support to the teams of leaders on the ground. Campaign approach: An annual campaign to hit a target number of pledges on a particular day each year is central to the Change Day design. The core leadership team, as well as local pledge-makers, can ‘chunk out’ this target over a longer period of time, kicking off the Change Day effort earlier in the year and developing tactics to achieve smaller pledge-targets along the way. We also recommend the development of a long-term strategy for Change Day. What should “Change Day” mean to people in ten years? To whom? To how many people in England? To how many people around the world? The team can then work backward to develop a long-term strategy that leaves room to incorporate new thinking and leadership each year. Emerging constraints, opportunities and learning will guide it over time. Goals and metrics: Mobilising people to take action will remain the central goal of NHS Change Day. We recommend that Change Day leadership set an even more ambitious target for the number of pledges secured in 2014. Leaders Everywhere The Story of NHS Change Day
  • 53. To develop impact measures, the Change Day core team can ask pledgemakers to report on their actions and outcome metrics on the online platform. They can also invite pledge-makers to commit their pledge for online “tracking” of learning and metrics after 3-, 6-, 9-, or 12-months. In addition, we recommend that the Change Day leadership team identify a small number of metrics that demonstrate the impact of pledging on patients and staff. These could include: impact on staff morale; number of pledges that involve “intentionally experiencing an aspect of the NHS through the eyes of another staff or patient”; or the impact of pledges focused on positivity on staff performance and patient care. Beyond impact measures, developing metrics around the NHS Change Day design elements is possible and desirable. How many people told an online or on-the-ground narrative to mobilise others to join their pledge? How many new relationships were built through Change Day? Has the pledge led to other voluntary or collective actions? How many people were inspired to join a particular pledge? Quantifying the design elements of the Change Day approach will help tell the story of how it is enabling distributed leadership, voluntary commitment, and new relationships to lead to innovation and improvement in patient care – and contribute to other organisational change efforts long after Change Day. Opportunities for research: Certain 2013 pledges took off like wildfire. For instance, over 3500 pledge-makers committed to smile at someone else (like patients or colleagues). At face value, one might assume that little impact could come from the act of smiling on one particular day. But there is a growing body of research around the effects of positivity, including smiling, on health and wellness – not only in terms of the impact on the person who is smiled at, but the person who is smiling! It boosts Leaders Everywhere The Story of NHS Change Day morale, leads to feelings of empathy, builds relational resources, broadens awareness, develops trust, and leads to better negotiations, better medical decisions, more creativity, more resilience, better memory for details, improved ability to focus, and improved perspective (Fredrickson, 2013: 60-69; Fredrickson and Branigan, 2005: 313-332; Schmitz, De Rosa and Anderson, 2009: 7199-7207; Rowe, Hirsch and Anderson, 2006: 383388; Isen, Rosenzweig and Young, 1991: 221-227; Waugh and Fredrickson, 2006: 93-106; Dunn and Schweitzer, 2005: 736-748; Kopelman, Rosette and Thompson, 2006: 81-101). This is an example of the endless possibilities for research partnerships with pledge-makers involved in Change Day, particularly around demonstrating impact. We encourage Change Day leadership, pledge-makers and researchers to invite and pursue these opportunities. Global movement: The NHS has sparked a movement that has gone global. Change Day 2013 included pledges from people the world over. Emerging clinicians and leaders from other healthcare organisations in Norway, Canada, Australia, Denmark, the United States, and beyond are keen to participate in Change Day 2014 – and lead local efforts to mobilise those in their own countries and organisations. Although initiated and branded by the NHS in England, all of us share the opportunity to embrace distributed leadership and voluntary collective action toward patient care and quality improvements. We recommend that the NHS continue its work to support global leaders learning from its approach, and to invite others to join them in a worldwide “Change Day” with no one particular organisational affiliation, but the same approach and objectives. To do so, we recommend virtually convening an internationally-diverse group of frontline clinicians, patients and improvement leaders to develop a global “Change Day” governance structure and online coordinating platform. The global platform could seamlessly allow for pledge-counts from each participating organisation or nation to contribute to a global 53
  • 54. count of pledges, while featuring various pledges to develop a global community. In addition, the online platform can be designed to allow for data-sharing and produce co-learning opportunities between countries and organisations. Finally, a global pledge could be highlighted as one possibility to pledge-makers everywhere as a way in which to harness worldwide collective action. Along these lines, we recommend that improvement leaders outside the NHS in England commit to at least two design elements of Change Day. First, follow the central premise of the Change Day approach: recruit leaders on the ground to lead the effort. It is important that Change Day leaders – everywhere – embrace the approach of distributed grassroots leadership and voluntary commitment, in contrast to senior leaders bringing Change Day to groups through top-down compliance models. Second, determine with frontline leaders what expression of Change Day makes sense within local contexts and constituencies. Already Change Day 2014 is a date that many healthcare leaders in the UK and around the world have put in their calendar: 3 March 2014. Core leadership team 2013 This is testament to the extraordinary leadership shown by a dedicated group of people in the NHS in England who imagined a mass movement of people taking action together to improve healthcare. More than that, it demonstrates that new models of distributed leadership can develop alongside traditional hierarchies; and that when “leaders everywhere” are mobilised, great things are possible. 54 Leaders Everywhere The Story of NHS Change Day
  • 55. REFERENCES Alexander, Ruth (2012), “Which is the World’s Biggest Employer?” BBC News Magazine at Ganz, M. (2010) “Leading change: leadership, organization and social movements,” in Nohria, N. and Khurana, R. (ed.) Handbook of Leadership Theory and Practice, Cambridge: Harvard Business School Publishing Bate, P., Bevan, H. and Robert, G. (2006), Towards a million change agents. A review of the social movement literature: Implications for large scale change in the NHS, NHS Modernisation Agency at Isen, Rosenzweig and Young (1991), Medical Decision Making, 11, 221227. Johnson and Fredrickson (2005), Psychological Science, 16, 875-881. Bennett, Nigel, Wise, Christine, Woods, Philip A and Harvey, Janet A (2003). Distributed Leadership: A Review of Literature. National College for School Leadership at Katwala, Sunder (2011), “NHS Makes Socialists of Us All, Says Tory MP,” Next Left: A Fabian Society Blog at Dunn and Schweitzer (2005), Journal of Personality and Social Psychology, 88, 736-748. Katwala, Sunder (2013), “The NHS: Even More Cherished than the Monarchy and the Army,” New Statesman at Fredrickson, Barbara L. (2013) “Increase Your Daily Diet of Positivity: Why & How,” Coaching in Leadership & Healthcare, The Institute of Coaching at McLean Hospital, pp. 60-69. Kopelman, Rosette and Thompson (2006), Organizational Behavior and Human Decision Making, 99, 81-101. Fredrickson & Branigan (2005) Cognition & Emotion, 19, 313-332. Granovetter, Mark S., “The Strength of Weak Ties,” American Journal of Sociology, Vol. 78, (May 1973), pp. 1360-1389. Kotter, John P. (2012) “Accelerate: How the most innovative companies capitalize on rapid-fire strategic challenges – and still make their numbers,” Harvard Business Review, November Ganz M (2010) Leading Change: Leadership, Organization, and Social Movements in Handbook of Leadership Theory and Practice, Nohria N and Khurana R (eds), Chapter 19, HBS Press Lynton and McCrea (2013), The difference a day makes….Interim Report for NHS Change Day 2013, at Leaders Everywhere The Story of NHS Change Day 55
  • 56. NHS Improving Quality (2013), “Biggest ever day of collective action to improve healthcare that started with a tweet” at NHS Institute for Innovation and Improvement (2011), “The Right Prescription: a call to action on the use of antipsychotic drugs for people with dementia” at otic_drugs.html Northouse, Peter G (2013) Leadership. Theory and Practice, 6th ed. London: Sage 56 Rowe, Hirsch and Anderson (2006), Proceedings of the National Academy of Sciences, 104, 383-388. Schmitz, De Rosa and Anderson (2009), Journal of Neuroscience, 29, 7199-7207. Snowden, David J. and Bone Mary E. (2007) “A Leader’s Framework for Decision Making,” Harvard Business Review, November Talarico, Berntsen and Rubin (2009), Cognition & Emotion, 23, 380-398. Waugh and Fredrickson (2006), Journal of Positive Psychology, 1, 93-106. Leaders Everywhere The Story of NHS Change Day
  • 57. APPENDICES Appendix A: The Story of Barking, Havering and Redbridge University Hospitals NHS Trust Just saying thanks helps reconnect us to why we came to our work: because we care about and love patients. Saying it out loud makes it real.” Who: Flo Panel Coates (Director of Nursing), Emma James (Communications Team Associate) & Ashley Brooks (National Patient Champion) How they got involved: Flo and Emma first heard about Change Day through a director at the Trust who made a pledge and supported Change Day locally and nationally. As Emma stated, “When Donna (director) first heard about Change Day, she asked me to help staff learn what it was about, how to get involved. I was responsible for the educational process at the Trust. We have regular staff meetings each month, and we started off gently telling people it was coming up, what it was, what you could do. Then we built it as a campaign. We had posters everywhere. Each week we did features on who was making pledges, and what they were. We focused on a range of staff members from a midwife to the Chairman of the Trust. Our aim was to make sure everyone in our organisation (6,000 people) knew about Change Day and to entice them to get involved and make a pledge.” Where: Barking, Havering and Redbridge University Hospitals NHS Trust When, pledged for how long: On Change Day and beyond What (Pledges) & Why: Flo Panel-Coates: Flo pledged that she would listen to more patients and staff. “For me it was about something I was already committed to doing, but I was being clearer to others about what I was doing and why. It allowed me to informally ask people’s views and opinions, and I have continued with that.” Emma James: Emma pledged to be a change agent. “I looked for ways to make change, and if I found those resistant to change, I committed to work with them to find another way… I never want to stand still as a person or organisation; we should always be looking to change ourselves and others to benefit the patient.” Ashley Brooks: Ashley pledged to protect the NHS. “I want to protect the NHS because I want it here for my children. At the moment, I am working to protect nursing staff. They are the first to get admonished for any problem on the front line.” As one part of protecting the NHS, Ashley pledged to say thank you to staff as often as possible. “Our staff aren’t thanked enough. I say thank you for saving my life, for saving my father. Leaders Everywhere The Story of NHS Change Day Ashley learned about Change Day from national Change Day team member, Jackie Lynton. He saw himself as a “conduit” between the national team and the Barking, Havering and Redbridge University Hospitals NHS Trust. In light of some negative press around the organisation at the time, Ashley saw Change Day as a chance to do something positive. He encouraged others to participate in Change Day by sending emails to his colleagues, and at first, no one responded to him. “People had huge pressure to deliver on things that were much bigger than Change Day. Understandably, we often look after the problems that are most urgent first. But in late November, I said if no one does this, I will give up on it! Then everyone wanted to make it happen and got together to move it forward.” This story illustrates the power of offering people a choice in the face of a challenge, particularly those that we share relationships with. 57
  • 58. Why they got involved: The urgent ‘moment’ surrounding Change Day was one motivating factor. As Flo stated, “On the one hand, we were responding to the Francis inquiry. The NHS was in trouble, and we recognized the need to do something differently. NHS Change Day provided that opportunity by focusing on contributions that individuals could make, instead of focusing on the problems that we face. Our director made a positive pledge to take action to encourage the openness and candidness of staff.” Change Day also provided an opportunity to experiment. “We chose to use NHS Change Day to try different things, to experiment. There is big stuff we need to do and we know that; but what we wanted to tell everyone was that each of us can bring something to the table; we don’t need to wait for someone to tell us. It’s about the little things we can do straight-away” (Flo Panel-Coates). Emma added, “Change Day empowered people to act. It allowed our staff to come up with their own pledge, declare it online, and do it without anyone else creating a barrier. It gave people a place to grow their good ideas. It also empowered the organisation to see where we could make large or small scale improvements by listening to people on the ground.” How the pledge worked: Flo’s pledge: Flo offered numerous examples of how she listened to more patients and staff – and then did something about what she heard. “Every Thursday I have a clinical day. That involves my going into departments to talk to patients and staff, ask them about their experience, what frustrates them. Some patients were very critical of not having hot meals in the evenings. I have become a champion of bringing hot meals back into wards for patients. A colleague of mine, Jackie, is a Director of Facilities, and she needed some support on this 58 issue. Although she is a formidable lady, it would have been hard for Jackie to champion this change on her own; she needed someone else who could reflect the view of the patients. I am the Director of Nursing, and I could help. We used NHS Change Day to springboard pieces of work like this – together.” Emma’s pledge: Emma worked with Ashley to develop a campaign approach to engaging other staff in Change Day. “Because it was a day, we built up to that day, and localized our campaign to our staff. We had a little whiteboard where people wrote their pledges in large print, and we took pictures of them holding them so we could post this visual commitment. It made it personal and specific to our hospital staff.” Emma publicised Change Day among matrons at their monthly meeting, in Staff Briefings (which in theory should have trickled into Team Briefings), through stories on the intranet, in the weekly staff newspaper, via desktop images on staff computers. She also visited wards to raise awareness of the campaign and spoke to staff on Change Day. She also enabled staff to submit pledges easily. Staff could make pledges by visiting the Change Day website, downloading a form and sending it back to the communications office or handing it in at the main information desks, using the electronic pledge form on the intranet, or tweeting their pledge to #feedback. “Forty-three people made pledges. At the beginning people pledged to smile more or say thank you; then bolder and bigger pledges emerged as we got closer to Change Day. It made people stop and think what they didn’t like and the role they could play in bringing about positive changes for staff, patients or the organisation as a whole. There were a few team Leaders Everywhere The Story of NHS Change Day
  • 59. pledges; and they may have been spearheaded by individual staff but by the time I met the teams everyone was enthusiastic about the pledge and wanted to play their part, too. The individual pledges were brilliant too. One top consultant committed to sitting in the waiting room to experience what our patients see and feel. We’ve followed him through the year to see how it is working, how it is going for him, and shared it with other staff.” “We wanted it to be about that day; and every year we are doing to do it. We have gone back to people who made pledges and asked them how it went and run articles on it in the staff newsletter. We will keep it running in the background until we start the build-up for Change Day 2014.” Ashley’s pledge: “One of the commitments that we made was to introduce something called the ‘Patient Champion.’ Prior to Change Day, we learned that when staff witness something or have concerns, they are afraid to raise them with manager or peers. Even though we have a whistle blowing policy, not one person has ever used it. I play a national role and am independent of the organisation; so I have become the patient champion. There is no fear of retribution or harm to reputation by raising concerns with me. Since June 27th, over ten people have contacted me to raise their concerns about other staff or practices. This is a very important change.” Flo added, “Ashley has helped us deal with the issues confidentially and fed back to staff what we’ve done as a result of what they’ve brought to him. The fact that we’ve had 10 people come forward demonstrates its value. They feel they are being listened to and are taking their concern seriously. Even if we can’t resolve it right away, we’re trying to make things better. And they won’t receive any backlash from management for the issues they’ve raised.” Leaders Everywhere The Story of NHS Change Day Lessons: Emma conducted an internal evaluation of what worked well and how they could improve in engaging more staff in Change Day. She submitted some of the following findings: What worked well: • Publicising the event: Most people had heard of Change Day by the 13th of March. • Staff pledge photos: Staff liked seeing the photos of other colleagues’ pledges in their departments. • Conversations at NHS Change Day stall & visiting staff in their departments and wards: On Change Day Emma and Ashley spoke to people about their jobs and what they did by asking: “How long have you worked here, why did you come to work here, what do you like, what would you change?” Staff opened up. By having a conversation, rather than just asking whether people had made a pledge, staff felt listened to and where more likely to make a pledge then and there. • Learning from staff: As Emma James reports, “Change Day gave staff the respect they deserve, by taking time to ask them, ‘What can we do, what can we be?’ There has been a tendency in the past to not listen to staff [because] you may hear things that you don’t want to. There was a different atmosphere around Change Day. The executives wanted to hear what staff thought, and they wanted those messages loud and clear. Those messages will help us transform the organisation to be a better place to work and for us to deliver a better service for patients.” • Senior staff backing: Senior figures supported the event, which signalled to staff that there was not a barrier to participate. • National NHS Change Day visit from Jackie Lynton: Jackie visited wards and departments, inspiring staff to take part in Change Day – which was evident from the numbers of pledges received from staff in the wards that she visited and their enthusiasm for Change Day even after making their pledges 59
  • 60. What can be improved: • Signals from senior leadership: Some senior leaders projected a feeling that the Trust had been under scrutiny and underperforming so everyone should already be working on ways to improve our services. They also dismissed simple pledges such as “keeping my patients more informed of delays in treatment or appointments” as things that staff should do anyway. It would have helped if they had led by example and made pledges. • Ownership by staff: Many still saw the effort as a top-down initiative that people were being ‘forced’ to take part in, rather than it being led by them. We need to engage more frontline staff in leading the effort; and we need to ask senior leaders to play a supporting role. • Confusion about pledges: There was confusion about what pledges were or who they were for. Some members made suggestions about things that the Trust should be doing, rather than making individual pledges. Nonetheless, these suggestions are being followed up on! • Being prepared to handle concerns that are raised: Cultural and interpersonal issues surfaced through Change Day. Four staff reported team members that were causing problems for the rest of the staff, being rude or underperforming. Being prepared to address these situations is important as we encourage people to identify areas for improvement and change! Recommendations: • Support pledge-makers by following up with them to see if they had fun, learned anything, or made progress of some kind. Encourage longer-lasting effects of pledges. • Debrief staff for any key issues, lessons or concerns that were raised through Change Day. 60 • Visit more wards to talk to staff face-to-face about what they care about, what motivates them to do their jobs, and how to improve patient care. • Be clearer about what a pledge is and is not. • Get senior staff backing, but invite frontline staff to lead it. • Work with unions at a national level and with staff side representatives at the Trust to get their backing and spread the word Ideas for involving the public: • Outreach: Teams made up of GPs, matrons, staff visit local churches, schools, mosques, etc., and explain what Change Day is and invite them to get involved. • Use Change Day to create awareness about how to access care: For example, our Emergency Departments are so busy, we can engage the public in learning more about walk-in centres, how pharmacists can provide advice for colds and coughs, etc. through Change Day. • Change Day could be a recruitment drive to get young people to consider a job in the NHS: We can show the diversity of roles from backroom staff to chefs, in addition to clinicians. • Building relationships with staff and public: Many people felt that recent changes to the NHS (i.e. the biggest reorganisation in 63 years) were undertaken without a mandate. During NHS Change Day 2013 we saw the Government trying to repair some of this damage by praising all the hard work and dedication of those who work in the health service. For Change Day 2014 staff can reach out to other staff and the public and ask them how to improve their experience of delivering or receiving care. Staff and patients should support changes to their health service. • Celebrities, sports personalities and those who have been helped by the NHS: Ask them to serve as representatives of the public face of the Leaders Everywhere The Story of NHS Change Day
  • 61. campaign to engage the public. They can champion NHS Change Day on morning and evening news shows (e.g. BBC Breakfast, The One Show). We could even ask the Royal Family and key public figures such as the Prime Minister and London Mayor whether they would visit Trusts, GP Surgeries and other NHS Facilities to say “thank you” to staff. • Work with TV channels to air health related documentaries and dramas: For example, the BBC could air special episodes of Holby City or Casualty, or re-run old programmes such as Carry on Matron. • Branding for kids: There could be a Change Day mascot for children to have their photographs taken, stickers, balloons – more fun! • Double-decker Change Day bus: It could travel to city centres to pitch Change Day as a road show with both national figures and local leaders. Changes in thinking and leading: Change Day helped amplify ideas and accelerate actions already percolating among staff. As Ashley related, “Change Day gave people permission to be creative and innovative and not be frightened to make commitments to improvement. That permission gave people room to take action to safeguard patients. It accelerated conversations to a higher level. Guardian Services is one example. Potentially Guardian Services would not have been discussed; Change Day was a great motivator for creative ideas! It helped to accelerate and amplify good work.” Flo related that it is the job of executive leadership to support efforts like Change Day. “It is our job as an executive team to create the type of environment that encourages people to do the right thing by our patients. We have to work to change the culture in the NHS. We tell people we want them to be innovative. We are constrained by doing things the way we’ve always done them.” In other words, Change Day helped people Leaders Everywhere The Story of NHS Change Day step outside of daily habit and behaviours. “Our job is to get people to see things and do things different, and the freedom to do that. We don’t have the ideas and solutions; that comes from our staff. We have to give them safety to act and not shoot down their ideas. We often hold people back; we want to keep people safe to make their own mistakes and try things and fail and succeed!” She added: “Most executive teams are not this way; but they want to be. We get caught up in our day jobs and we miss the point about culture and the environment and the impact on others in our organisations. We don’t make things easy for people; we are battling a system that isn’t always ready for it.” NHS Change Day approach: This kind of modelling contributes to a shift in culture. Emma James, a junior member of the Communications Team, remarked, “I’m junior in the NHS, and I have found it to be very hierarchical. But I was most impressed with the executive leadership exercised around Change Day. We had some lovely directors who said ‘you are just as important as me.’ Having that feed through the organisation – Change Day helped us get the ball rolling to get a shift in culture – we are all in it together, it’s not just about those at the top. I want that to be felt throughout the entire organisation.” Ashley recognized that Change Day builds on other improvement efforts built on social movement design elements. “Change Day for me is the natural progression of the organizing work from the Calls to Action… It is how you present a call to action, making it as simple and effective and emotional as possible so people commit. A call to action requires everyone to take action; and if we do, we can’t fail. Most people get it – if we all do something together, if we do it as a large group, we can get something 61
  • 62. done. It’s not top-down and it’s not bottom up; it’s people coming together – like a church – to get something done. Let’s change things, let’s ask whether we are including others, let’s ask whether we are doing what we know is right. And it all starts with a pledge.” As a younger leader, Emma noted that it felt like an effort led by the thinking of Generation Y. “The whole approach is very modern. It is grassroots, people tweeted, used social media – it is not something that we’ve done before. It was like borrowing ideas from political campaigns, and using modern elements that show we are the next generation – and we are taking ownership in the NHS.” Ashley reflected on ways to improve the Change Day approach in future years. “Change Day 2013 focused on employees and staff of the NHS. It should be a lot bigger. It should include patients – there are millions of patients who love the NHS. Let’s focus on the public and patients. If we go back to World War II, one of the biggest marks of success for the warwas: ‘What can you do for your country?’ We need to ask: ‘What can you do for your NHS?’ Change Day has a huge energy behind it; and we have to widen its scope.” 62 Leaders Everywhere The Story of NHS Change Day
  • 63. Appendix B: The Story of Birmingham Children’s Hospital Who: Janette Vyse, Lead for Patient Experience & Participation; Ellie Milner, Patient Experience & Participation Support Officer; Harriet Giles, Health Promotion Support Worker; Jane Powel, Lead for Health Promotion What: At Birmingham Children’s Hospital, we pledge to go that extra mile and make someone smile! Where: Birmingham Children’s Hospital When, pledged for how long: NHS Change Day itself (with some ongoing actions) How Birmingham Children’s Hospital got involved: The Patient Experience & Participation Team at Birmingham Children’s Hospital describe their approach as focusing on “developing a culture of working in partnership with children, young people and families.” “It’s about patient communication and how that impacts on patient outcomes and experience,” says team leader Janette Vyse. “That’s what underpins our enthusiasm.” So it was only natural that team member Ellie Milner, who had herself been a patient representative at Birmingham Children’s Hospital, responded so enthusiastically when she first heard about NHS Change Day. The rest of the team were equally positive seeing Change Day as a “fantastic opportunity to have an impact.” Having looked at the Change Day pledge wall, the Patient Experience & Participation team knew the project would benefit from support from the Executive Team and approached Chief Nurse Michelle McLoughlin, Executive lead for Patient Experience & Participation, who was equally supportive and agreed Leaders Everywhere The Story of NHS Change Day to put the pledge up in her name which the team felt “helped to define it as a hospital-wide pledge.” Why Birmingham Children’s Hospital got involved: “We thought that Change Day would be another way to get the message out about the importance of patient experience and the idea that little things can make a big difference. This was one day when we could do lots of little things that could make a big impact.” Why this pledge: The Patient Experience team decided early on that they wanted to involve as many people across Birmingham Children’s Hospital as possible on NHS Change Day – a local version of the national mobilisation. They were also keen to come up with a pledge that would not exclude non-clinical staff – so enabling staff to take action to support other staff as well as patients was an important early consideration. “We sat down as a team and discussed the options,” say Janette Vyse. “We didn’t have huge amounts of time so there was a real sense of urgency.” Initially the team considered asking staff to make their own individual pledges but they felt that this would make it harder to get the whole hospital to take part. It was during a brainstorming session that the “go the extra mile to make someone smile” idea surfaced. It appealed partly because it was simple and gave individuals the opportunity to come up with an action that was suitable for their own part of the hospital. It also reflected the evidence showing that it does indeed matter to patients that staff smile. For staff facing multiple pressures, it was also appealing to be able to offer a smile to each other, suggesting that “it’s ok to say that we do things well.” 63
  • 64. How the pledge worked: The BCH strategy for Change Day had two elements. First, the Patient Experience & Participation team planned a number of activities that would bring a smile to patients. “The idea was to come up with something that would make a child or young person smile,” says Janette Vyse. With the backing of the Chief Nurse they secured a small amount of money to pay for face painters, a balloon modeller, a magician and, for the older children, a beautician to spend the day in the hospital. The team coordinated the activities moving the various entertainers from one part of the hospital to another and from ward to ward. The second part of the strategy was to recruit other staff from across the hospital to come up with their own actions and to provide them with any support and encouragement they needed. Emails were sent to Heads of Nursing and Ward Managers but, more importantly, Ellie Milner and Harry Giles were regularly in and out of the wards as part of their day job and were well known by the clinical staff. Janette Vyse explains, “When they were doing their ward visits, they would talk to the ward manager about Change Day and provided lots of posters and the pledge slips! Both Ellie and Harry’s natural enthusiasm really helped to ‘sell’ the day!” These face-to-face visits were crucial to securing support across the hospital as was the fact that the pledge that staff were being asked to make was entirely voluntary and doable: “We weren’t asking people to do something that was a big additional workload.” The team was able to share examples of pledges that were being made in other parts of the hospital and to offer to help if needed on Change Day itself. Outcomes: As a result of all the work that had gone into their pledge, 13 March 2013 was very special at BCH: “The day had a lovely feel – people smiled! And people commented on that continually. What made it such a 64 success was that people participated. We saw it visibly happening – seeing smiles on the faces of the patients and how staff had embraced it.” The positive effect spread to everyone involved: “People who participated got a sense of wellbeing – if you give, you get. There was a real sense of caring for each other as staff, of camaraderie, or doing something together.” Many of the specific pledges were made by wards and units: • The staff in one ward laid on breakfast for parents who had to stay overnight in hospital with their children while in another ward they brought in cakes and in a third provided additional art and craft activities. • The Outpatients staff teamed up with the volunteers who ran the Art Cart to make a wall covered in paper-plate smiles. • The Burns Unit gave out bravery certificates and stickers after dressings were changed. Other pledges and actions were individual and could be very simple: “We know of one person who phoned a colleague in another department just to thank them for the work they do.” The Clinical Photography unit pledged to ask for feedback from each person that they came into contact with during the day. A little nervous at first, they found that it was in fact a very positive experience with a number of ongoing benefits. First, they became more skilled at having effective feedback conversations. Second, they found that they received much more relevant and valuable feedback than they usually received on their standard feedback from. Finally, they identified this approach to receiving feedback as being much more effective for a service that forms Leaders Everywhere The Story of NHS Change Day
  • 65. only a small part of the patient journey (most patient feedback typically referring to ward-based activity). This experience has been so positive that the Clinical Photography unit has instituted regular ‘feedback Wednesdays’ which have also been taken up by in-patient Pharmacy, and the CAMHS team. Lessons: It was a very different experience asking people to volunteer on the basis of commitment rather than trying to get them to agree because they were being required to participate: “We were honestly able to say ‘we would love you to!’” The reason that people participated was because the pledge was relevant and personal: “People instinctively knew that it would make a difference to patients. Changes in thinking: “Putting in the effort to make someone smile does have an impact – on the staff who are ‘going the extra mile’ as well as the patients. It helps to keep patient care at the forefront of our mind. “We will approach next Change Day with a greater sense of certainty that we will be able to make a difference – because we already have made a difference.” Changes in leading: For the Patient Experience & Participation team “there was a sense of having led something between us.” Change Day also provided the opportunity for staff who would not normally consider themselves to be ‘leaders’ to step-up and show just what fantastic leaders they could be. “The approach felt naturally values-based and caring which seems appropriate for the work of BCH. “It reinforced what we already know – that it is possible for little things to make a big difference.” Leaders Everywhere The Story of NHS Change Day 65
  • 66. Appendix C: The Story of Jonathan Griffiths Who: Jonathan Griffiths, Member of Governing Body of Vale Royal Clinical Commissioning Group What (Pledge): Jonathan committed to spending the day in a wheelchair in order to appreciate, promote, and raise awareness about the experiences of wheelchair users and International Wheelchair Day. Where: Jonathan did everything from a wheelchair – from using the toilet to travelling in a wheelchair-accessible taxi – at his two places of work, the Vale Royal Clinical Commissioning Group and Swanlow Practice. When, pledged for how long: Jonathan spent the day in a wheelchair on Wednesday, March 18, 2013. As part of his Change Day pledge, he then shared his experience with others on his CCG’s blog: and How Jonathan got involved: A “newbie” to Twitter, Jonathan created a Twitter account at the beginning of 2013, which is where he first learned about Change Day. Jonathan immediately knew he wanted to be part of Change Day but did not know what to pledge. Later, Allison Phillips, a Clinical Project Manager, asked Jonathan to participate in International Wheelchair Day on March 1. Jonathan was unable to make the commitment on this date, so he instead made it his pledge to NHS Change Day 2013. 66 Why he got involved: When Jonathan read the NHS Change Day Tweets and reviewed its website, its model of distributed leadership appealed to him. He liked that anyone could commit to being a part of something larger than themselves, connecting their local actions to a national community with shared values. He believes in leading from example. “This is how I wish to lead. It’s not for other people. It’s what I believe in; this is me being me.” Change Day afforded him the opportunity “to put himself out there a little bit.” Why this pledge: Jonathan wanted to promote International Wheelchair Day and share the lessons he learned with others. It was important to him to better understand, even in a limited way, the experience of those who spend their lives in wheelchairs. How the pledge worked: “I arrived at work at 9am. The wheelchair was waiting for me. I took some time to work out how get it ready for use, and realized that I needed a spanner to adjust the footplates. The estates department kindly came to help me. Between us we set them correctly. I hadn’t realized that I needed to be an engineer just to use the wheelchair! “Just getting to a desk was difficult. The building I work from is old, and we have no lift. My usual desk is on the second floor. We had arranged with the staff working downstairs for me to have somewhere to work, so I was sat with another team. I felt disconnected from the people I usually work with, unable to just ask a quick question to our Office Manager, or walk down the corridor to ask someone something. “I developed a backache from sitting down all morning, and the cuffs on my shirt sleeves were dirty from self-propelling the chair. Leaders Everywhere The Story of NHS Change Day
  • 67. “I negotiated myself into the disabled toilet. Again, easier said than done with ladders and vacuum cleaners left in the corridors. Once arriving at the toilet I found a builder filling his bucket from the disabled bathroom sink after having removed the u-bend. A small delay was required while he sorted this out! “Getting through the doors to exit the building was a real challenge. Getting down the ramp was okay, although rolling ‘downhill’ was slightly disconcerting! Once at the bottom of the slope I had no access out into the car park because a car was parked in the disabled bay blocking the way out. (As we have no disabled staff assigned to work out of the building, and already have a car park issue, people have taken to parking in the disabled spaces.) I also discovered that my footplates were too low and catching on the ramp. I had to rely on someone to wheel me back up the ramp. (He later informed me after the event that he nearly dropped the chair and me.) We finally had to move two cars to get me out of the building. “A wheelchair-accessible taxi arrived on time and I was dealt with efficiently and professionally. Being wheeled up a ramp into the vehicle which was then clamped to the floor was an experience, but I felt safe and looked after. Apparently it costs about £5000 to modify a vehicle for wheelchair use. It cost me £22 for a 10-mile journey. “At one point I tweeted a picture of myself saying, ‘I may be smiling but this is hard work.’” Outcomes: This pledge impacted Jonathan on a personal level by developing his empathy for wheelchair users. “I am much more aware of the difficulties facing wheelchair users in just getting about. Everything was so much more Leaders Everywhere The Story of NHS Change Day difficult than I ever expected, and I have found new respect for people in wheelchairs who just get on with it and make it look easy. “Of all the challenges of the day, the social isolation was the worst. I was unable to be with my team, unable to get to them. I was not expecting this to feel as difficult as it did. “And although I might have imagined what it was like spending time in a wheelchair, it was only when I did it that I really began to understand. Clearly spending one day in a wheelchair does not mean that I know what it is really like, but it has increased my understanding a little bit. It certainly increased my respect for wheelchair users.” During the day, Jonathan’s pledge also affected those working with him. Members of his team were forced to meet on different floors and locations so that Jonathan had physical access to meetings. “My colleagues had to find me a desk on the first floor; they had to move the team brief downstairs; they had to seek me out in a different location when they had questions. No one seemed to mind, but it did emphasise how we are not usually set up to manage with a person in a wheelchair.” Jonathan also asked another team member to chair the meeting as his NHSCD pledge. “She got to experience what it was like for me to chair our meetings.” Colleagues also stopped to talk to Jonathan about his experience throughout the day, curious to learn from his insights. “They wanted to know what it was like.” Jonathan also shared his experience more broadly via Twitter and blog posts, as well as via a press release and telephone interview with a local 67
  • 68. newspaper. He received re-Tweets and comments that buoyed and inspired him, and that connected him to those involved in Change Day across the nation. “I felt part of something bigger than myself or my pledge. I built new relationships as I Tweeted about my experience throughout the day. And I have carried on with blogging and Twitter. Change Day was a good introduction to the power of social media in connecting us.” Since Change Day, Jonathan has asked team members to swap perspectives with each other in order to improve their individual and collective practices. “I asked a receptionist to sit in surgery with me. Then I sat with her to learn about her approach to what she does. By better understanding each other’s concerns, objectives and practices, we were able to come up with a better way to achieve our shared goals.” Lessons: “What struck me about the day was how the little things which we all take for granted became so much more difficult. Things like getting through doors, closing toilet doors behind us, driving a car and climbing stairs. There was one thing, however, which I really wasn’t expecting: social isolation. Being unable to share an office with my usual team, being unable to call over to the Office Manager to ask what time the meeting is, being unable to nip down the corridor to ask someone their advice. I was stuck downstairs in a building with no lift, and even if there had been a lift, I would have thought twice before making the trip. “In one meeting that I was chairing, I was only able to access the far end of the room in my wheelchair. The tea and coffee and biscuits were at the other end of the room. I was unable to wheel myself [to the tea] because the table and chairs were in my way. And even if I had got there, I couldn’t have wheeled myself back carrying the cup of tea. I had to rely on others to help me. This took away my feeling of independence, and 68 sometimes I didn’t want to ask for help. At the same time this made me feel socially isolated.” Change in thinking: “When I tell patients who are wheelchair users that I spent the day in a wheelchair, it immediately improves our relationship. They appreciate that I went to a little effort to better understand their lived experience, and I appreciate that I only touched on it in a limited way. “Spending a day in a wheelchair also led me to thinking about the importance of always placing the person at the centre of what I am trying to do. Spending time in their shoes, or in this case on their wheels, challenged my views. On the day I tweeted that I thought all NHS staff should spend time in a wheelchair. I still believe this is true. I challenge you to consider doing this. You may learn something unexpected.” Change in leading: “I see patients who have mobility issues all the time. I visit them sometimes feeling slightly irritated that they have not made more of an effort to get to surgery to come and see me. I try and get through my visits quickly, feeling the clock ticking, with more work waiting for me back at surgery… The patients that I am talking about may spend their whole day at home with carers nipping in two or three times a day, being otherwise left alone, unable to go out, or even sometimes unable to get out of the chair, or out of bed without assistance. Intentionally reducing my mobility for a day has opened my eyes to how awful this can be.” Because Jonathan feels a greater sense of empathy for them, he spends more time with them. “When I am on a home visit with someone elderly and housebound, I know that I might be the only personal contact that patient has with anyone that day. I accept the cup of tea offered. I ask about things Leaders Everywhere The Story of NHS Change Day
  • 69. that go beyond their medical problems. It is good for them, and it connects me to why I care for others. It helps me see them as people instead of medical problems and fosters a better patient-doctor relationship.” NHS Change Day approach: “I joined this effort through Twitter and the Change Day website. I saw what others were doing across the country, and when I tweeted my experience, other people that I didn’t know responded to me. I tweeted ‘wheelchair waiting for me this morning’ with a photo of the wheelchair and sent it to @NHSChangeDay and got Tweets back immediately. I felt like I was a part of something bigger than myself. I was a part of a national community of like-minded people trying to improve the NHS in their own ways. I think this could be inspirational to some people. Others will want to do their own thing. “It seemed to me like the simplest ideas were the best. I remember seeing a pledge where a provider called on patients in the waiting room rather than using his call buzzer. This is a simple but powerful change in day-today behaviour. It doesn’t take much to do, but the relational impact on patient care can be meaningful. “These actions can trigger other things. Even if for some it is a morale boosting day, it is worth our spending time to figure out ways to better appreciate and enjoy the work we are doing. “The pledges open your mind to see that the way things are done doesn’t have to be the way things are done. We all fall into patterns, we assume they are the best ways to go about things. NHS Change Day encourages us to question our assumptions – maybe we are right, maybe we are wrong. It makes us learn something. It makes us ask: What can I try next? It certainly made me look at my own ideas around access and patient experience, and it gave me permission to try new things. “People were left to decide what their pledge was themselves. You could see what others were doing, but there wasn’t a ‘we want you all to do this’ approach. Some people did big things, others did little things – the point was to do something that you found meaningful and could commit to. That was good for ownership reasons. People could say, ‘I thought of that, I did that,” rather than being told what to do. You own it, don’t you? You can run away with it and be your own change maker. I did. “It is a great example of a bottom up approach. It isn’t your boss telling you this is how you should improve. You decide for yourself what you want to do differently and set a goal. It is like giving employees a day a week to work on their own projects. Did you know that Gmail was invented that way? Google encourages innovation by encouraging its employees to pursue their ideas. You get better ownership if you give people a chance to do that. Bottom up means better ownership in the NHS. “I think it is okay for Change Day 2014 to roll out the things that worked well – so long as people are still exercising their own choice. People can be invited to learn about pledges that could create more meaningful impact or join a pledge that others are doing or support someone else’s pledge. “Personally I don’t think this approach is threatening to senior leaders. I can see how others might but they need to get over it. It’s just a different style of leadership. NHS Change Day models distributed leadership. We need to move in that direction as a whole organisation. And we need to look for models of integration that cross health and social care.” Leaders Everywhere The Story of NHS Change Day 69
  • 70. Appendix D: Authors’ Biographies Kate Hilton, JD, MTS Kate Hilton is a Director at ReThink Health. Founded in 2007, ReThink Health is an incubator that supports the emergence and application of new ways to accelerate the transformation of health and health care. ReThink Health works to enable a genuine metamorphosis within the health system to occur – one in which different stakeholder groups come together in unexpected ways to redefine solutions and bring them to action. At ReThink Health, Kate specializes in the field of community engagement and leadership. She designs health campaigns, teaches leadership skills, and strategises with leadership teams to take collective action, particularly in multi-stakeholder settings. Kate’s work with ReThink Health focuses on developing its community engagement work, distance learning programs, and leadership trainings. Kate is also a Principal in Practice for the Leading Change Project at Harvard University. Kate currently co-leads ReThink Health’s regional health transformation work in partnership with Dartmouth-Hitchcock and The Dartmouth Institute in the Upper Valley of New Hampshire and Vermont. She serves as curriculum coordinator and faculty in ReThink Health’s distance learning program. She is also a coach in a Special Innovations Project supported by the Centers for Medicare/Medicaid Services. This project applies community engagement skills and systems dynamics insights to improve outcomes in areas of low performance and high costs associated with chronic disease states like CHF and COPD. 70 From 2010-12, Kate led a community mobilisation team to catalyse the Healthy Columbia campaign, exploring the contributions that organising can make to the transformation of health and health care in South Carolina. In 2010-11, Kate served as lead coach and trainer on an 18-month program looking at how theory, practice and approaches from community organising can contribute to quality improvement and cost reduction in the NHS. In partnership with colleagues at the NHS Institute, this culminated in an adaptation of an engagement framework specifically for the NHS (Call to Action: Delivering QIPP and achieving common purpose through shared values and commitment). From 2010-12, Kate was the Founding Director of Organising for Health and designed and led its distance learning course. Kate has coached leadership teams and led community engagement trainings for health care organisations including the Institute for Healthcare Improvement, Centers for Medicare & Medicaid Services, Colorado Foundation for Medical Care, Counties Manukau District Health Board of New Zealand, Harvard Vanguard, Danish Society for Patient Safety, South Carolina Hospital Association, and IHI Open Schools. Kate taught in Marshall Ganz’s organising course at Harvard Kennedy School in 2004 and 2009; and she co-designed and led the first distance learning version of the course in 2010. She works closely with Ganz and Leading Change to design curriculum, lead trainings, teach courses, write articles, and coach teams in leadership skills and organising strategy. Leaders Everywhere The Story of NHS Change Day
  • 71. Kate received a J.D. from the University of Wisconsin Law School in 2008, an M.T.S. from Harvard Divinity School in 2004, and an A.B. from Dartmouth College in 1999. She is licensed to practice law in Wisconsin and Massachusetts. She lives with her husband, Andrew, son, Hans, and Labrador retriever, Jethro, in Lyme, New Hampshire. Chris Lawrence-Pietroni, BA, MA, MPA Chris is a Director of Leading Communities – a new organisation that works at the intersection between community engagement, systems leadership and service design. He works mainly across health, social care and local government in the U.S. and U.K. He is also a Senior Associate at the Institute of Local Government Studies (INLOGOV) at Birmingham University. As a Senior Associate at INLOGOV Chris consults to a number of local authorities on organisational design and leadership development (particularly as it relates to enabling co-production) and is a core faculty member on the National Graduate Development Programme for Local Government. Chris has worked extensively with the National Health Service developing capacity around community organising and mobilising. Most recently Chris led trainings for the National Institute of Clinical Excellence and the Health Protection Agency to enable them to incorporate an organising theory of change into their work on hospital acquired infections. He was previously a coach and trainer on an 18-month program looking at how theory, practice and approaches from community organising can contribute to quality improvement and cost reduction in the NHS. In partnership with colleagues at the NHS Institute, this culminated in an adaptation of the organising/mobilising framework specifically for the NHS (Call to Action: Delivering QIPP and achieving common purpose through shared values and commitment). Chris is currently supporting Coventry City Council and Birmingham Community Health Services Trust as part of the national Local Vision Programme. Both oganisations, their partners and communities are applying social movement theory and practices to major public health challenges. Chris has delivered community organising trainings in Serbia (where the campaign focus was on reducing corruption in healthcare) and been a facilitator for the Harvard Kennedy School’s Leadership in the 21st Century Executive Education Program. Chris collaborates with ReThink Health in the U.S. and has recently coached Quality Improvement Organisations in Louisiana and Baltimore as part of a Center for Medicare Studies Special Innovation Project. The project focused on applying both community organising and systems dynamics insights to improving outcomes in areas of low performance and high cost associated with chronic disease states such as CHF and COPD. Chris has worked extensively in the non-profit and public sector in the U.K., and until July 2009 he was Director of Corporate Strategy and Pubic Affairs for the Local Government Association. He then spent a year studying at the Harvard Kennedy School and graduated with a Masters in Public Administration when he was awarded the Lucius N. Littauer Fellowship. He holds degrees in History from the Universities of Oxford (BA) and Warwick (MA – with Distinction). Leaders Everywhere The Story of NHS Change Day 71
  • 72. #NHSChangeDay The focus of this report is on an improvement initiative developed by the NHS Institute for Innovation and Improvement (NHSI); a national body established in July 2005 to support the transformation of the NHS, through innovation, improvement and the adoption of best practice. NHS Institute for Innovation and Improvement closed on 31 March 2013. NHS Improving Quality (NHS IQ) is the organisation now responsible for driving improvement across the NHS. For further information, go to For more information about NHS Change Day, go to Published by: NHS Improving Quality - Publication date: November 2013. © NHS Improving Quality (2013). All rights reserved. Please note that this product or material must not be used for the purposes of financial or commercial gain, including, without limitation, sale of the products or materials to any person.