NHS Integrated Service Improvement Programme

The Role of the External Change Agent in NHS Service Transformation

September 2007 Table of Contents

1 Introduction...... 1 2 Why the ISIP Demonstrator Programme Chose to Use External Change Agents...... 1 3 What do we mean by ‘External Change Agent’?...... 2 4 What makes using External Change Agents a realistic proposition?...... 3 5 What we did...... 5 6 What did we learn overall?...... 7 7 Top Tips for Clients and ‘External’ Change Agents on making the role work...... 8

1 Introduction This paper explores the role of the external change agent within the context of the NHS Integrated Service Improvement Demonstrator Programme, which ran from the end of 2006 until the end of September 2007. The demonstrator programme set out to work with 16 Local Health Communities, which were all seeking support to build on their ISI plans by transforming healthcare services through the application of benefits led integrated change programmes, and in particular ISIP’s Road Map for Transformational Change (RTC) and the tools and techniques associated with the approach. The themes addressed by the LHCs which took part in the demonstrator programme ranged from urgent and emergency care, to various long term conditions and elective care/18 week initiatives. Each local health community received on-site tailored support to deliver their programme of change from a designated change consultant in the ISIP team.

2 Why the ISIP Demonstrator Programme Chose to Use External Change Agents From the very start of the Demonstrator Programme it was clear that the nature and complexity of the task faced by the local health communities (captured in Diagram 1) meant that the challenge of providing each with the support they needed was unlikely to be met by simply offering funding or by providing external programme or project managers. Instead, the ISIP team opted to offer each LHC a named Change Agent. A key aspect of the rationale for doing this, apart from the need to support LHCs in developing their own sustainable solutions rather that managing their change initiatives for them, was the realisation that each site was likely to require a breadth and depth of expertise that only a team of people could provide. Although the external change agents were expected to forge strong links with designated demonstrator sites, they were also expected to function as a resource across the programme as a whole in their particular areas of expertise.

Diagram 1: The challenge of integrated service transformation

Role of External Change Agent in Service Transformation Page 1 of 10 3 What do we mean by ‘External Change Agent’? Although some define the Change Agent as the person responsible for the overall change effort1,2, that description actually best fits with what the Office of Government Commerce (OGC) refers to as the Senior Responsible Owner (SRO) for the change initiative3. Our experiences lead us to an alternative description, also reflected by the OGC (SRO4 Efficiency Team), which characterises the Change Agent as: Someone who acts as a catalyst for social, cultural or behavioural change. Change Agents may come from within an organisation’s workforce or be external to it. External change agent appointments are usually time limited or linked to the life of the programme or project they are supporting. They may come from national teams such as the NHS Integrated Service Improvement Programme4, the NHS Clinical Governance Support Team5 or the Health and Social Care Change Agent Team6, be seconded from other roles or NHS organisations, or come from private sector suppliers of advisory and consultancy services. The change agent’s role is distinct from the often more detail focussed ‘orchestrating’ responsibilities of the programme or project manager. However, it is these positions that those regarded as effective change agents within an organisation are often asked to fill. External change agents generally do not implement plans or take responsibility for decision making. Their preoccupation is with supporting change leaders and programme and project teams in negotiating the transition between the current state and the desired future state. The role is about facilitating, through coaching, mentoring and knowledge transfer, the development of new skills and behaviours in others. The external change agent acts a ‘Critical Friend’7 to the programme or project team, challenging accepted norms, and offering fresh perspectives based upon their diverse organisational experience and learning. That’s not to say that external change agents don’t provide hands on support when necessary, they do. However, when they do, it is usually in relation to a specific short lived piece of work e.g. producing a risk register, or communication plan, rather than assuming responsibility for a project or programme work stream. By supporting and facilitating rather than assuming responsibility for the change process, external change agents promote local ownership of the changes delivered, which is vital if the benefits to be derived from the transformation are to be sustained.

1 Swansburg R C (1996) Management and Leaderships for Nurses 2nd Edition. Jones & Bartlett Publishers, Massachusetts 2 McNamara C (2005) Field Guide to Consulting & Organisational Development. Authenticity Consulting LLC, Minneapolis 3 Office of Government Commerce, Successful Delivery Toolkit www.ogc.gov.uk/User_roles_in_the_toolkit_senior_responsible_owner.asp 4 NHS Integrated Service Improvement Priogramme www.isip.nhs.uk 5 NHS Clinical Governance Support Team www.cgsupport.nhs.uk 6 Department of Health, Health & Social Care Change Agent Team www.changeagentteam.org.uk 7 Costa AL & Kallick B (1993) Through the lens of a critical friend Educational Leadership 51(2) October p.50 Role of External Change Agent in Service Transformation Page 2 of 10 4 What makes using External Change Agents a realistic proposition? In addition to the points above there are a number of other advantages associated with deploying ‘external’ change agents in support of a change programme or project. These include:

Bringing skills and techniques to bear which are not available within the organisation Although expertise in the use of techniques like Lean, Statistical process control, Six Sigma and Transition Management is growing within the National Health Service, in many organisations there remains a significant skill deficit in these areas.

Facilitating knowledge transfer and skills development amongst the client organisations workforce By ‘doing with’ rather than ‘doing to’ the client workforce, the external change agent not only introduces new skills and techniques, but enables the acquisition of new capabilities, which enable the client team to carry on the work of managing change after the consultant has left. By building capacity in this way the ‘external’ change agent aims to avoid client dependency on their services; they are in effect seeking to build their own obsolescence into the assignment.

May have more legitimacy than internal change agents because perceived as unbiased and unfettered by any internal relationships and dependencies Every organisation has its own local political context and history. At times this can undermine the effectiveness of internal change agents. Although external change agents inevitably need time to understand the organisational context, they come without the relationship history that can hinder others.

Representing additional capacity available to the programme or project team Very often it is not so much a skill shortage, but a lack of available human resources, that can stand in the way of programme or project progress. Fundamental resources issues need to be addressed at the initiation stage of any initiative, and by the steering or management group thereafter. However, when necessary, external change agents can undertake specific pieces of work like facilitating stakeholder mapping events, developing communication strategies and running service model workshops, in order to keep progress on track. Caution: A potential consequence of using an external change agent in this way is that it could undermine their perceived independence and objectivity, and compromise any skills transfer objectives the project might have.

Role of External Change Agent in Service Transformation Page 3 of 10 Bring diverse organisational experience (within either the public or private sectors) to bear in order to inform and stimulate review, audit and benchmarking activities An external change agent who doesn’t have a health background has to work hard to overcome the disadvantage of not being familiar with the culture and language of the service. These change agents have to demonstrate the transferability of their skills and experience, which may result in a longer time lapse between commencement and demonstrable results. However, once they are accepted, the experience they bring to bear in areas like Lean and Business Process Redesign can bring a new perspective, which itself transforms a change project.

Bring a degree of detached objectivity to the change process which those who are part of the organisation and its current state might not Regarded as divorced from the vested interests of those within, external change agents focus on the success of the programme or project, which means their views and advice are more likely to be taken on face value, than it would be from an insider suspected of a partisan agenda. Of course external change agents simply being used to disguise the pursuit of a predetermined course of action are quickly seen through.

A means of accessing other extra-organisational resources and skills relevant to the programme or project Whether part of a National DH or NHS team, or a private sector advisory and consultancy business, external change agents invariably have access to a broad range of expertise and resources in addition to that which they themselves can offer. These resources can be deployed to support the client organisations objectives, something almost certainly not available to an internal change agent.

Being a role model for the new behaviours associated with changes and cultural shift being sought As Knotter & Heskett (1992) put it “be an unconventional outsider who becomes the physical embodiment of the desired culture”8. Of course, this advice comes with a few caveats. The desired new culture has to be one that the change agent can identify with. The external change agent cannot be so ‘unconventional’ as to be easily marginalised and must be properly able to fulfil the role. Finally, the stakeholders must understand the relevance of the new behaviours.

5 What we did The three brief case studies which follow highlight just some of the different challenges faced by the ISIP Change Agents, and how, whatever the intentions

8 Knotter J P & Heskett J L (1992) Corporate Culture & Performance. The Free Press

Role of External Change Agent in Service Transformation Page 4 of 10 at the outset the change agent has to respond flexibly to the situation in which they and those they are working with find themselves.

Role of External Change Agent in Service Transformation Page 5 of 10 Role of External Change Agent in Service Transformation Page 6 of 10 6 What did we learn overall? The experiences and reflections of those who worked as external change agents within the ISIP demonstrator programme reflects that of others9, and can be summarised into a number of key principles for those in such roles:  Have a clear sense of purpose o Fully appreciate the need for change o Understand the vision and scale of what is being sought o Have a realistic concept of the timescale for change o Have an agreed brief for the role they are to undertake o Formulate early on an exit strategy for closing the relationship  Have the capability to act o Have leadership and interpersonal skills, and political awareness o Have the knowledge and skill to promote and support the change process o Quickly understand the organisational context for the change o Understand the broader national strategic context against which the changes are being made  Be strategically connected within the client organisation o Identify and be well connected with sources of formal and informal power and influence within the organisation o Have direct access to the Programme or Project SRO, sponsoring Directors and the CEO of the lead organisation o Understand the broader senior management agenda within which the change initiative exists o Encourage senior managers to learn by experience, and offer feedback on strengthening future change initiatives  Be critically reflective o Promote a non-threatening environment to articulate lessons learned o Promote a systematic approach to learning from failure and success o Offer and promote critical reflection on all plans, events and reports.

9 Joint Information Systems Committee InfoNet HEFC funded networking and information resource www.jiscinfonet.ac.uk Role of External Change Agent in Service Transformation Page 7 of 10 7 Top Tips for Clients and ‘External’ Change Agents on making the role work

Overt support for the external change agent role The external change agent needs good support mechanisms and a degree of bestowed power in order to question and challenge the status quo, and the often vested and influential interests behind it. As important as the overt patronage of the executive sponsor, is the ease with which the change consultant can access both the sponsor and other members of the organisations senior management.

Get the chemistry right The success or failure of the external change agent role hinges on forging a close and effective working relationship with the leaders of the change initiative within the client organisation. The external change agent is a coach, mentor and critical friend; if the chemistry isn’t right get a different change agent.

Build trust Key to an effective relationship is trust. Developing trust means spending time with the programme or project team. It also requires clarity about the nature of the external change agent role; discuss it with the change leaders and overtly record it. Share it with the programme or project team and answer any questions they might have about the role. Adopt an initially non-judgmental empathetic approach to those involved.

Be appropriately challenging The external change agent should challenge the team to push boundaries, address obstacles and work more effectively together within the team. In doing this the change agent must consider the local context and weigh the capability and capacity of the team to respond. Although the external change agent isn’t responsible for the success or failure of the programme or project, he or she is responsible for observing and advising on how the team approaches its work, and for failures which result from pushing people beyond their capabilities.

Plan the exit strategy from the start Client and change agent should work together to prepare for the end of the relationship. Develop a plan which supports any knowledge transfer objectives and set out timescales for the hand over of responsibilities assumed by the external change agent. The aim is to ensure the work of change continues after the external change agent has moved on.

Role of External Change Agent in Service Transformation Page 8 of 10 References: (1) Swansburg R C (1996) Management and Leaderships for Nurses 2nd Edition. Jones & Bartlett Publishers, Massachusetts (2) McNamara C (2005) Field Guide to Consulting & Organisational Development. Authenticity Consulting LLC, Minneapolis (3) Office of Government Commerce, Successful Delivery Toolkit www.ogc.gov.uk/User_roles_in_the_toolkit_senior_responsible_owner.asp (4) NHS Integrated Service Improvement Team www.isip.nhs.uk (5) NHS Clinical Governance Support Team www.cgsupport.nhs.uk (6) Department of Health, Health & Social Care Change Agent Team www.changeagentteam.org.uk (7) Costa AL & Kallick B (1993) Through the lens of a critical friend Educational Leadership 51(2) October p.50 (8) Knotter J P & Heskett J L (1992) Corporate Culture & Performance. The Free Press (9) Joint Information Systems Committee InfoNet HEFC funded networking and information resource www.jiscinfonet.ac.uk

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