• change management
• organisational change

Quality improvements require change. Performance improvements require change. When a health system aspires to both over a sustained period there is a serious risk of “change fatigue”—key players getting tired of new initiatives and the way they are implemented—invariably the key players needed to make the changes work and bring in the improvements.

The National Health Service (NHS) in England has pursued improvements in performance and quality for almost 10 years, but particularly since the Labour government came to power in 1997.^1,2 Significant extra funding has been made available by central government, and structures and systems have been established to ensure that the NHS “modernises” its practices. These programmes have achieved results: waiting times are down for elective procedures, access to care has improved, and more resources for staff and treatment are available to managers and clinicians. The improvements in performance have been achieved through the relentless application of targets via a managerial regime working “top down” in the NHS. Quality and service improvements are encouraged through a wide range of initiatives embraced principally through the Modernisation Agency, an agency of government focused on changing processes and systems to improve both quality and performance.

In this month’s QSHC Gollop et al³ address the issue of scepticism and resistance to changes in working practices. The authors rightly point out that this resistance is principally among medical staff, and that the reasons include personal reluctance to change, misunderstanding of the aims of improvement programmes, and a dislike of the methods by which the programmes have been promoted.

Managers cope with change in a different way from clinicians (accepting that many clinicians have significant managerial responsibility). It has become almost customary practice for managers to pursue new centrally dictated imperatives and targets in publicly funded health systems. Clinicians are motivated by different incentives and dwell in a professional domain where individual professional autonomy is paramount and allegiances tend to be to professional societies and peers.⁴ They dwell in these domains for a lengthy period of time, in contrast to managers whom they perceive to move through the system as quickly as any number of new initiatives (“revolving entities”). Gollop et al acknowledge that doctors are the key players to engage with the change process, and the ones offering the most powerful resistance. Ask if clinicians are suffering from change fatigue and the answer is most probably “yes”. Delve a little deeper and we may understand why.

Clinicians want to change things for the better for their patients and for working practices. They perceive an endless stream of initiatives, see many of them “fail” and reappear with a new name, see conflicting directions of change, and a plethora of initiatives so great that they fail to see the final purpose or connecting logic. They believe that “managerialism” has eroded their autonomy. What is probably more important is that they do not have the space or the time in which to pursue these programmes. Publicly funded health systems do not offer the luxury of resources which similar change programmes receive in private industry. There is little time in their personal schedules, little dedicated resource, and little room to manoeuvre to make changes happen—sometimes, literally, no physical space to rearrange services.

The answers should be in the field of organisational development. Ironically, this is not a body of knowledge and practice generally accepted by clinicians.⁵ What does motivate people is a shared vision “hooking” into personal desires to improve practice, evidence that the process behind the programme might work, and resources to help them do it. Trust in the leader and in the process taking change forward is also essential. Leadership is critical as people cannot simply be ordered to change. There must be a sense that the prize at the end of the change process is greater than the sacrifices they are making.

One major change programme which did engage clinicians successfully is clinical governance.¹ This major programme in the NHS focuses on the organisation’s duty of quality and provides clinical and management responsibility for systems to ensure quality of service. As a new development it probably encountered the least resistance of any of the new national initiatives within the NHS—why? It was “going with the clinical grain” in terms of service improvement and had a set of aims which were clearly understood. Furthermore, its title and the terminology seemed to make sense and resources were attached for its implementation over a programmed time scale. Contrast this with the introduction of so-called hospital “re-engineering” initiatives in the early and mid 1990s—frightening terminology, minimal evidence base from the US, and a patchy process of introduction. It was a good idea badly implemented and it failed to engage the majority of clinicians.

Are we suffering change fatigue? There is a danger that we are. Can we avoid change fatigue among the followers we wish to create? The answer is “yes”, if we align the incentives such that there is congruence of aims, lead in the right way, avoid jargon, attach resources and time, and engender trust through delivery. Difficult—but worth it.