NHS England and NHS Improvement
Helen Bevan Göran Henriks
@HelenBevanTweet @GoranHenriks
Creating tomorrow today:
how to (and how not to) help people
build their agency at every level

2 |
Agency: The power and ability to make choices and
act on them
 Individual agency: People get more power and control in
their own lives: through thinking differently, self-efficacy
(confidence and belief that I can make things happen)
shared decision-making and/or self-care
 Collective agency: People act together, united by a
common purpose, harnessing the power and influence of
the group and building mutual trust
#qmicro @HelenBevanTweet @GoranHenriks

3 |
3 |
• Agency is vital to improving the value of the
contribution that health care services makes to
health
• Change efforts are far more likely to fail because
of lack of agency, than because of lack of
improvement skills, capability, resources or
methodology
About agency
#qmicro @HelenBevanTweet @GoranHenriks

4 |
I felt sad when I went home from the
hospital, and disappointed that I had been
treated so badly.
I’m going to the ER because of kidney stones for the second time in a
short period of time. At the doctor's appointment, I find an arrogant
attitude.
When asked how are you on the VAS scale? I answered 6-7. The doctor
then says: You know that a severed foot is VAS 10.
I didn't feel trusted. I've been in the emergency room for about 4 hours
without anyone asking me how I'm doing. I go out into the hallway to
ask staff when I'm going to be examined or what's going to happen. I ask
two staff, one of whom replies: You know we have sicker patients who
can't stand on their feet. When I'm in as much pain as I am, you can't be
still.
In connection with the discharge, the same doctor comes in who has
talked to me before. I get a medicine bag with morphine tablets. I was
not told how many, what kind or how often I would take them.
The next day, I urinated out the kidney stones at home.
Treatment

5 |
Why didn't the doctor listen to me?
Why did I have to suffer unnecessarily?
My back had been hurting for many years. Last year I
had a herniated disc. I was at the orthopedist when I
felt something was not right in my back, but the
doctor said that it will get better even though I
repeatedly pointed out that I was in terrible pain and
ignored how badly I walked.
I was referred to primary care.
I wanted a second opinion and got it and came to
another hospital. They could immediately see that
something was wrong. As soon as the doctor saw me,
they said, "How are you doing?" It looks like you are
struggling. X-rays were done. They could see that the
pelvis has sunk and there was an immediate surgery.
Communication and participation

6 | Source: @NHSChangeDay 6
#qmicro @HelenBevanTweet @GoranHenriks

7 |
Well prepared team
Co-production builds agency
Active patient and relatives
We become succesful together!
#qmicro @HelenBevanTweet @GoranHenriks

8 |
What do I
need?
What can I do
myself?
More
knowledge
Tools
What help do
I need?
What help is
available?
Through
healthcare
Digital
solutions
Network Society
What if the patient's process started from a place of
agency?
Photo by Sara Riggare

9 |
https://youtu.be/DVjIRlKmE8o
#qmicro @HelenBevanTweet @GoranHenriks

10 |
Agency applies
at any age
#qmicro @HelenBevanTweet @GoranHenriks

11 |
Health visit for 3 year olds

12 |
Hälsobesök med hälsosamtal i
Barnhälsovården
10 mån
1 år
föräldrar
18 mån
2,5 år
3 år
4 år
5 år
Barnhälsovården 2021

What we can learn about agency
from a Ghanian bead partnership?
 a non-governmental organisation (NGO) based in Ghana with a mission of
alleviating poverty
and
 a Danish company that manufactured and sold bead jewellery made from
recycled crushed glass
Set up a“Business-NGO partnership” to make beads, aimed at alleviating
poverty in villages in Eastern Ghana, with a worthy goal to break the poverty
cycle through education and alternative livelihood opportunities
• Viewed as successful by the NGO because it delivered on its promise in
terms of providing resources and competences for the women it employed
• But actually made the lives of the villagers worse
• “Competency without agency” Cross sector partnerships as capitalism’s new development agents:
reconceiving impact as empowerment
https://research-api.cbs.dk/ws/files/58518921/Cross_Sector_Partnerships_as_Development_Agents.pdf
#qmicro @HelenBevanTweet @GoranHenriks

“Competency without agency”
1. Lack of co-production and power sharing
2. Hand-picking of employees
3. Unstable employment
4. Having to travel to work
5. Specialist nature of the skills
6. Lack of voice
Cross sector partnerships as capitalism’s new development
agents: reconceiving impact as empowerment
https://research-api.cbs.dk/ws/files/58518921/Cross_Sector_Partnerships_as_Development_Agents.pdf
The resources and competences, which the women acquired through the bead
partnership (income, technical skills and new knowledge), did not help them to build their
agency (the power and ability to make choices and act on them). It did not provide the
women with better opportunities to live the lives they desired
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Source of graphic: Lionel Francois
Agency:
the power and
ability to make
choices and
act on them

COMPETENCY AGENCY
COMPETENCY- the quality of being competent; capacity and skills &
AGENCY – the power and ability to make choices and act on them
• Improvement skills
• Project/programme management
• Innovation and design methods
• Analytics
• Process facilitation skills
• Influencing skills
• Coaching skills
• Self-efficacy
• Collective action
• Building belonging
• Embracing diversity
• Relationships
• Connections
• Social action
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Agency
How do we build the confidence, courage and power to manage our own health and
/or challenge the way things are and get things changed?
• Tactics that start with me, on the inside, to build my own self-efficacy - the
confidence and belief that I can make things happen
• Tactics that start with others, on the outside, collaborating to build the power to
make things happen
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Self-efficacy
There is a positive, significant
relationship between the self-
efficacy beliefs of a change agent and
their ability to facilitate change and
get good outcomes
“The ability to act is tied to a belief that it is possible
to do so.”
“Our sense of conviction that we can successfully
execute a task to produce the result we want to see”
Albert Bandura

Mentalisation -theory of mind
• The ability to understand one´s own
and other´thoughts, desires, feelings
and needs
• Holding mind in mind
• To see ourselves from the outside and
others from the inside
• Understanding misunderstanding
• Know yourself as others know you but
also know your subjective self (your
own experience)
Source: Bateman and Fogany
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When leaders can cultivate both inner and
outer skills, it increases their chances of success
in large complex change by 52 percent.
Deborah Rowland
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SynEnergy: we are not outside of the
change:
we ARE the change
Source of graphic: Adapted by Helen Bevan from Reos Partners
Others
I am a
co-creator of
the change
I am part of
(within) it
I am leading or enabling
the change
I am helping others to
change
I am apart from
(above or outside) it

Change is inherently relational: it depends on our
ability to work with others to enable it to happen.
In a system
Helen Bevan and Goran Henriks
“
SynEnegy

Ten ways to build self-efficacy & agency