Background Within the UK National Health Service (NHS) the move to Sustainable Transformation Plans/Partnerships and Integrated Care Systems reflect the increasing need and expectation for transformational change at a system level across both health and social care boundaries. Transformational change is complex, emergent and dynamic requiring new, non-traditional forms of leadership which are highly relational and persuasive.
Aim of the study The current study aimed to explore a small number of NHS senior leaders’ experiences of undertaking transformational change within their localities over a period of a year following participation in a national transformational change programme designed to enhance personal capabilities.
Method Four pairs of leaders working on different change programmes took part in the study and were interviewed at three time points about their approach to their change work. The data were analysed qualitatively using template analysis.
Results A core theme of Creating Allegiance to an Emergent Future World was developed. The senior leaders created allegiance to the transformational change through a process of Connecting on three levels: relational, with purpose and vision and through practice. Allegiance creation was attempted even if the transformational change work at the year-end was deemed successful or not.
Conclusions The study highlights the types of leadership behaviours employed by the participants reflecting the complexity and social construction of their transformational work. The findings provide further evidence to the existing system leadership literature as well as emphasising the importance of creating stakeholder, multilevel buy-in to healthcare transformation.
- transformational change
- health system
- care redesign
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Transforming the UK National Health Service (NHS) in the 21st century has become an imperative due to increasing demand, monetary constraints and an ageing population experiencing multiple comorbidities and complex health and social care needs. Developments since the Five Year Forward View1 published in 2014 has included the creation of Sustainable Transformation Plans/Partnerships2 and more recently Integrated Care Systems,3 acknowledging the need to undertake system-wide transformation across multiple health and social care boundaries. A recent paper investigating the foundations of success for NHS primary and acute care vanguard programmes highlights the importance of relationship-building, transparency between partners and the colocation of teams across boundaries.4 System-wide transformation therefore requires system leadership, a paradigm shift from the notion of leadership by authority undertaken within clearly demarcated boundaries to leadership that is shared, adaptive, flexible and distributed involving the need to build cross-organisational alliances through engagement, influence and persuasion.5
An effective system leader focuses on creating the conditions for transformational changes and its sustainability. A primary role is that of relationship builder, but also system leaders have additional core capabilities: a wider system perspective, the ability to foster reflection and generative conversations and the ability to shift from problem-solving the present to cocreating a new future.6 At the heart of system leadership lie personal qualities of the leader: reflexivity, the ability to cope with ambiguity and ways of thinking to translate the difficult and complex as a means of galvanising others.7 Leaders are therefore expected to socially construct the problems they face. Significant ambiguity and stakeholder diversity mean that transformation challenges can typically be viewed as wicked problems, often having both technical or adaptive8 aspects that have to be jointly addressed. Within the NHS, there is recognition of the compelling need for collective system leadership across organisational boundaries as the future of healthcare involves delivery across interdependent services with a focus on overall patient care.9 There is also recognition that these types of leadership capabilities need further development and support.10
The aim of the current study was to create an in-depth understanding of how healthcare leaders undertake transformational change at the system level over time. Senior (but not executive) healthcare leaders attending the Transformational Change through System Leadership (TCSL) programme, a 5-day set of workshops originally developed within the NHS Institute for Improvement and Innovation and currently delivered by the ACT Academy of NHS Improvement, were seen as an ideal group to involve in gaining an understanding of their experience of transforming healthcare.
Recruitment and participants
The main author submitted information about the study, protocol and consent forms to the UK Health Research Authority for a decision on whether the study constituted formal research requiring ethical approval.
Participant pairs consisting of a Director and a Programme Manager attending the TCSL programme were provided with information about the study and a request was made for volunteer pairs to be interviewed at three time points over a year about their experience of the programme and their transformational change work. Volunteer participants completed consent forms, providing consent for the study and for their anonymised data to be published. Initially, five pairs expressed an interest in being interviewed, of which four pairs were interviewed on three occasions and their data used for analysis. Consent was sought again from each participant prior to each interview. One pair withdrew part way through the process due to workload pressures and their data are not included in the final analysis.
Brief details about the four pairs (using pseudonyms), their transformational change project and progress made at the year-end point are summarised in table 1. All the participants worked for the NHS within England at a senior level. The range of projects appeared typical in terms of scope and breadth compared with the projects undertaking by the other participant pairs on the programme.
The participant pairs were sent additional information about the study and optedin via email. Consent to take part in the study was also gathered at this stage and again at the start of each interview. Interviews were undertaken by the second author in addition to one other member of the TCSL teaching faculty (including the first and third authors). The main focus of the interview was in two parts: the first to explore how participant pairs were progressing with their transformational change work and the second part to investigate what and how they were applying change tools, concepts and techniques in their projects, including those taught during the TCSL programme. Each interview was undertaken approximately at 6-month intervals, with the first being undertaken mid-way through the programme, and lasted between 60 and 90 min.
Interviews with participants were audio recorded, transcribed verbatim and analysed using template analysis.11 Template analysis is a form of flexible qualitative thematic analysis used widely within organisational and management research and is particularly useful for studying differing perspectives within those environments.12 Template analysis involves the use of an a priori coding template, applied to qualitative data, refined and further developed over a number of analytic iterations. Unlike some other qualitative approaches, it is not bound to a specific epistemological position.13 The method followed that of King14 and was undertaken principally by the first and second authors with additional support provided at the interview stage by the third author and latterly through peer analysis by the remaining authors.
The transcribed accounts were read and reread and the first four transcripts coded initially on a line-by-line basis. The a priori template used at the first stage of the analysis comprised the TCSL curriculum topic areas and many data items were initially coded using these topic titles, for example, ‘role-modelling’. The authors remained open to new insights within the transcripts and different codes were also used, for example, in vivo codes, ‘honest broker’. Later transcript analysis became more focused and selective coding was undertaken in larger sections. At the same time, codes were clustered into themes and the emergent themes were named and grouped. From this, the authors developed microstories, essentially worked-up themes developed from each participant pair account and which formed the next iteration template. Over 50 microstories were generated. Following this, the microstories were presented to peers (third, fourth and fifth authors and a leadership special interest group) and reorganised according to higher order themes pervading across all accounts. The theme model developed from the peer-analysis process was then further refined during a final iteration which included returning to original transcripts to ensure good grounding in participants’ accounts.
Based on the analysis, one core theme titled Creating allegiance to an emergent future world was generated. A second major theme titled Connecting was generated which provided the means by which allegiance was primarily created. Connecting also comprised a number of subthemes. See figure 1 for a visual representation. In addition, a number of other secondary themes were developed titled Adapting, Managing anxiety and Managing polarities. However, due to the brevity of this paper the findings are not reported on here.
The primary means by which the participants of the study undertook transformational change was through the process of Creating allegiance to an emergent future world. Creating allegiance incorporated the development of their stakeholders’ psychological, emotional and practical sign-up to the transformational change to a new and emergent future state (world). The term allegiance reflected the primarily relational work required to garner support for the transformation and highlighted the emergent, complex, fluid and unpredictable nature of transformational change. The participants sought to create this allegiance to transformation in others through a process of Connecting. Primarily through the analysis, three types of connecting were identified: relational, with purpose and vision and through practice (see figure 2).
Irrespective of the success or otherwise of participants’ transformational change efforts at the 1-year mark, they described themselves as organisational and system integrators; aiming to be non-partisan in their approach to creating allegiance to transformation; this enabled them to move fairly freely and flexibly with their organisations and systems to work with stakeholders and build relationships:
‘I have allegiance to the system not to individual organisations’ … let's bring those three organisations who it’s going to impact on into a room. So, there was myself and three chief execs and I literally, you know, probably naively, I don't know, but blatantly, ‘This is where we are, systems, we need to work as a system going forward. A provider, you currently provide this, do we feel that's the best place to go forwards? Let's have a conversation around it.’ (Jane—interview 2)
Participants also spoke about using system-specific language as part of their role to signal their system allegiance and to start to shape others’ focus onto a broader perspective:
I suppose I was quite pedantic really with saying it’s all about system leadership, it’s about team, the teams type thing. I think pedantic where it’s going to have a negative, but actually I think it’s had quite the opposite here. People can see the chief execs are signed up to this system leadership… I do think that has been quite a significant change and more and more in just the regular dialogue, the regular vocabulary that’s happening. People are talking about ‘I’m the system leader for’…So they’re actually being spoken and that wasn’t happening even six months ago. (Andrea interview 2)
Participants engaged in various forms of connecting activities in order to create allegiance. Three different forms were identified.
Participants described a range of ways to make connections with stakeholders to create allegiance through building high-quality relationships. To fully create allegiance, participants were required to access more senior executive staff in order to build personal relationships where they could advocate for the transformational work being undertaken and garner full support, sponsorship and engagement. This involved skilful, emotionally intelligent and insightful personal behaviours such as positive role-modelling, creating a safe environment by which honest and open conversations could be undertaken and engaging in ‘brokering’. Many participants described themselves as ‘honest brokers’; creating allegiance through a position of neutrality to create conditions for stakeholder agreement and compromise:
What I've been really focusing on for the last two months is getting out and about and engaging with the huge number of stakeholders that we've got, to try and understand what they want to achieve, what's their understanding, where do they see blockages, what are the opportunities. So to start engaging and having very, very open conversations… So my first two months, I think, if I look at my diary, and the reports I'm doing for the steering group, they are about engagement, engagement, engagement. (Neil—interview 1)
So at this point what I've agreed with the chief execs is that the honest broker in this, around representing all the providers, is Jane, and she works for everybody and all organisations. (Andrea—interview 1)
I think there's also something about a clarity around the structure and how I try and take what I call some of the pink and fluffy conversations or ideas and try and bit by bit put them down and layer them down and add a little bit more detail so maybe it's actually something that's on a piece of paper that people can then really start to buy into and add to. So I hope I bring some of that. The honest broker-type role. (Jane—interview 1)
Connecting with purpose and vision
For successful transformation, participants aimed to frame the vision and ambition for transformation to make it as accessible to as many stakeholders as possible. Where visions for transformations were in the process of being created, participants sought to gather broad stakeholder representation in the visioning process. However, where visions were already present or had been created in isolation by senior teams, it became increasingly vital that participants framed the visions in multiple ways in order to generate shared ownership of the vision statement to create allegiance. A key means of achieving this was to translate a high-level vision or statement of future intent into everyday practice; what different practices and ways of working are required in order for the vision to be actualised:
What you're looking for is to understand that this thing that's being discussed is around helping you to up-skill your staff, to develop new and innovative ways of caring for your patients, to be able to co-produce plans, and to become part of a group of providers where you can get some support going forward. It's not about words like vanguard. (Ellen—interview 2)
So, you know, we've got to have our ducks in a row with all the bits that we've learnt through the course, and preparing ourselves so that we can get them and say, 'This is the high level service spec, but how do you want this vision to rollout for you locally? So what does it mean for you as a team?' and start to bring them in to engage them in the process, so that they feel that they own it and they feel part of it. (Anna—interview 2)
Connecting through practice
While the former Connecting subthemes were principally undertaken through dialogue and relationship-building, connecting through practice was predominantly activity based, structural and practical (although built on collaborative relationships). Participants sought stakeholders’ commitment and responsibility to areas and streams of work through practical sign-up and senior responsible officer ownership of key pieces of transformational activity. To aid this process, participants gathered insights and intelligence from front-line staff on wards, in departments and teams in order to enhance their system understanding and identify stakeholders who were willing to undertake projects and oversee key activities. On a more organisational or system structural level, participants assisted in developing processes and procedures to join up and integrate separate or isolated workstreams. Connecting through practice, involved participants enabling stakeholders to sign up and commit to the transformational change work by physically (and metaphorically) signing on the dotted line:
I'm trying to sort out the leadership for the workstreams… So at the moment, as part of my engagement, I'm trying to identify the right people to come on board and take leadership of those workstreams. (Ellen—interview 1)
We didn't impose specifics on them; it was very much down to them to come up with ideas and thoughts on how they achieved that…. So it was done very much in partnership with them. (Anna - interview 3)
It's not come from us. We've told them we want a joined-up approach, we need to make some savings, we need the system to work in an integrated way. They've gone away and they've designed it and delivered it. (Anna—interview 3)
Less successful pieces of transformational change work at the 1-year mark highlighted themes related to disconnection; serving as a counterpoint to successful transformation requiring connections to be made. Most often disconnection was identified as challenges with senior executive staff fully supporting or engaging with the transformation, lack of shared ownership of the vision for transformation and lack of alignment across multifaceted workstreams:
That’s the bit I don't think we're connecting. Even if your organisation looks different, what are the work streams which sit at the core of the organisation which then must pervade everything? (Daniel—interview 1)
Allegiance creation through connecting was seen as the core process and set of activities by which the participants of the study approached their transformational change work. The concept of allegiance creation specifically appears under-represented within the research literature and is worthy of further investigation. Connecting occurred at three levels: relationally, through vision and purpose and through practice. Ultimately these levels all relied on participants having collaborative relationships with stakeholders of the transformation, and allegiance and connection were achieved through various means such as framing,15 role-modelling, having honest conversations and linking workstreams into strategic groupings.
Heifetz and colleagues9 16 use the term ‘adaptive leadership’ to first distinguish more traditional forms of leadership involving direct use of hierarchical authority and power from leadership by influence within emergent change, but also to describe a set of leadership behaviours people employ when faced with complex change. Adaptive leadership requires personal resilience and reflection, the ability to harness conflict constructively and to mobilise others to take on new roles and responsibilities. Adaptive leaders find ways to work at the edges of their authority, encouraging productive disequilibrium. Certainly these attributes appear in the accounts of the participants and their attempts to create allegiance fit well with Heifetz and colleagues’ conceptualisation.
The concept of adaptive leadership presented by Heifetz and colleagues and participants' leadership behaviours clearly also resonate with those qualities and capabilities described within the system leadership literature. There are many clear parallels between the findings of this study and the key personal values, behaviours and skills demonstrated by effective system leaders.7 8 Certainly, while the participants were demonstrating many attributes of a system leader, they were operating at a level of seniority below that of chief executive officer; this is relevant as those participants whose transformational change was floundering at the 1-year point describe frustrations with the leadership styles of their senior executive teams. Further research may be useful to examine further the interplay between leadership behavioural preferences and how senior executives are influenced.
The findings of the study resonate with similar themes also presented by Bushe and Marshak17 in their description of the ‘dialogical mindset’ of transformational change leaders. Taking a social constructionist perspective, leadership behaviours arise and are shaped through interaction with stakeholders within organisations and across systems. The narratives of transformation are powerful vehicles to mobilise others and leaders can help create these through their endorsements, role-modelling and use of language. For the participants, those who appeared most successful at the 1-year point were role-modelling allegiance to their system transformation, using collegiate, system-focused language and were framing the vision for change in ways to engage stakeholders at all levels. Another way to describe their behaviours is that participants were attempting to create social representations of the transformational change work through interpersonal communication as a means of enhancing stakeholder collectivity and cohesiveness.18 Unsuccessful transformational change efforts tended to demonstrate a lack of these behaviours from participants’ senior executives, despite participants’ best efforts.
Limitations of the study
From any study relying on volunteer participants to recount their experience, the limitations of a self-selected sample are clear; the participants in this study may well have increased levels of confidence and self-assurance in their leadership capabilities than others within the programme group. Interestingly, although the transformational work had not necessarily made progress at the year-end, it is apparent that the participant group were highly reflective and mature in their accounts and all appeared to be using similar behaviours to create allegiance. Clearly too, the study involved a small number of participants and away from the core themes which were well represented across the group, some of the subthemes had weaker evidence and were less saturated. The method of template analysis allows for the testing of a priori concepts as well as allowing emergence and while highly flexible, there are limitations in the core analysis of the data being undertaken within a faculty team who all deliver teaching on the same programme. Attempts were made to mitigate this by use of multiple rounds of peer review as well as involving coauthors not delivering programme content at the time.
The concept of allegiance creation requires further research as it appears under-represented within the literature, particularly as part of the process of transformational change, rather than as an outcome of change or behaviours towards leaders. Additionally, the participant group, although senior, were not executive leaders within the NHS (eg, Chief Executive Officer). Although it might be argued their lack of executive status allowed them greater freedom and ability to work across organisational boundaries, it will be helpful to extend the research to executive leaders to identify whether similar concepts and behaviours are present.
The study provides a process and examples of behaviours of how NHS leaders attempt to undertake transformational change across organisational boundaries. The concept of allegiance creation as a primary process appears new and requires further research. The process of connecting at different levels does reflect existing research on system leadership behaviours within a social constructionist frame. NHS leaders require leadership skills that are highly relationally based but are also pragmatic and practical. An effective leader of transformational change might be conceptualised as principally a connector but with a system-level allegiance and loyalty.
The authors acknowledge the time and contribution to this study from the participant pairs. They also acknowledge the NHS Institute for Improvement and Innovation for the original design of the TCSL programme and its subsequent contributors and faculty members.
Contributors AT planned and conducted the study and wrote the paper. AS and JRAT planned and conducted the study and contributed to the writing of the paper. LG and PM were involved in the analysis of the findings, peer review, and contributed to the review of the paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Ethics approval The Health Research Authority classified the study as service evaluation, not requiring formal ethical approval.
Provenance and peer review Not commissioned; externally peer reviewed.
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