Is change the only constant in the NHS?

Matthew Taylor

 Hello and welcome to this one-off bonus episode of Health on the Line. The focus of this episode will be on the Change Academy. You want to know what the Change Academy is? Well, you are going to find out in a minute from two people who've been very involved in it; a faculty member and someone who's been on that programme driving change themselves. 

But before I can talk to them, it's the AstraZeneca Change Academy and therefore it's very important just to say some things to be clear about the basis of our conversation. So, the intended audience for this conversation, our UK healthcare professionals and other relevant decision makers. This podcast has been developed in collaboration with AstraZeneca with Dr Richard Jones and Dr Llinos Jones are contracted by AstraZeneca as guest speakers in this episode. And finally, the Change Academy is a non-promotional service initiated and funded by AstraZeneca and offered to the NHS as donated goods and services.  

So, like a lot of people, Richard in the health service, distinguished people like yourself, I could spend 20 minutes reading your CV, your achievements, but introduce yourself in the way that you'd like to introduce yourself.  

Richard Jones 

Thanks very much Matthew. I'm a consultant cardiologist in a very busy district general on the south coast of England in Portsmouth, I'm associate medical director in the hospital, but in this sphere, really I'm interested in change and have been for many years. 

My observation over my career has been that many clinicians and their colleagues see their role as treating the patient in front of them to the very best of their ability, quite right.  

Many also understand the importance of trying to improve the overall system within which the care is delivered, but none of us really receive any training in change management as our medical careers progress. So that's really the angle I came from.  

I was lucky enough to do a master's with the Royal College of Physicians and Birkbeck College on medical leadership. And during that, one of the things we majored on was change and it really opened my eyes as to how complex change is and how difficult it is to achieve successful change, but how that there are ways and tips of how to improve your chances of making a successful change. And that's the sort of journey I've been on.  

Matthew Taylor 

Great. And Llinos, I'm going to ask you to introduce yourself in a moment but while I'm talking to you, Richard, let's just pursue this angle for a moment. 

For those people who are new to the idea of the Change Academy, and we are proud to be partnering with AstraZeneca around the Change Academy here at the Confed. Can you tell us a bit more about what it is and how it works? Because you are a faculty member. 

Richard Jones 

Yeah, so again, on my travels around the country trying to introduce a change in the world of heart attacks, I came across many committed and very talented clinicians who could see that a change was required but didn't really have the tools. 

And so the Change Academy was born out of that observation. It's a way of bringing together people, NHS doctors, nurses, and managers, into a safe environment where we can try to impart the nuts and bolts of how to make a successful change happen.  

The academy itself works on a sort of face-to-face basis for two of the days, and then we do things virtually and at the end of the year, delegates will come and present their projects that they've been working on, with our support, over the year.  

And that's a very humbling moment when you see what has been achieved. And again, this, I suppose, speaks to the idea that really the NHS needs thousands and thousands of change makers. We can't change everything in a top-down way, especially when resources are so scarce. 

So, the Change Academy is about taking, working frontline clinical folk and managers and trying to give them those skills so that we can make a thousand flowers bloom.  

Matthew Taylor 

That's great. And Llinos, I don't know whether it's worse to over pronounce the beginning of your name or under pronounce it, but I'm clearly going for the over pronouncing, so I'll see how the arrow goes. 

Tell us a bit about yourself.  

Llinos Jones 

Well, that was perfect, actually. Thank you for that last one. I'm Ilinos Jones and I'm a respiratory consultant working at Mid Yorkshire with a special interest in asthma, difficult as asthma in particular, and very, very pleased to be able to come and speak to you all today about the Change Academy. 

I was a delegate on the one of the first cohorts of the Change Academy.  

Matthew Taylor 

And tell me both, I'll start with you Llinos, and then go to Richard, what do you think...? I should tell you a bit about myself in this regard, which is that I am not an expert on the health service. I've only been working in the sector for, for four and a bit years, and I regularly find myself in rooms of people who've had 25, 30 years of experience. 

But I do think I know quite a lot about change. Really, that's been a consistent theme and the various jobs I've done in politics and think tanks and campaigning and various things. And I have to say, I think the very often the notion, the model of change, particularly the model of change from the centre of the health service, NHS England, the Department, now one organisation, it often feels to me to be pretty, well, not very sophisticated, I put it that way.  

So, Richard, starting with you, what do you think is the kind of biggest mistake that we tend to make when we think about change in the health service?  

Richard Jones 

I think the biggest mistake is not starting with a clear plan, which is evidence based. So, in medicine we love our evidence base, especially in cardiology. 

But when it comes to something like change, we're perhaps not aware that there is a very sound evidence base, and I particularly favour the Kotter, approach. And I think a failure to follow a model like Kotter, which we could talk about in a bit more detail, it's very simple. Failure to follow that sort of roadmap increases your chances of failure. 

And I think the second thing is probably that those working at the coalface often recognise that there is a need for change, but they don't have the tools or the support to make that change happen. And you can go away for a day and think about the change that's required. But as soon as these people go back to the coalface, you are swamped by the clinical work and all the good feelings about change tend to get overtaken by clinical needs. 

And the NHS does not have that huge body of change agents who are there to support clinician. We need the people at the front line to be the change agents.  

Matthew Taylor 

And Llinos, when you heard about the Change Academy, what was it that attracted you to participating in the programme?  

Llinos Jones 

Well, I was a recipient of a very nice grant, and it was to benefit patients who wouldn't necessarily always have agency or have their own voice. And so I felt a huge amount of responsibility to really do justice to the project that I started and undertaken. And the thing about the Change Academy was that it provided me not only with background in change and doing it, as Richard was saying, with an evidence base and you know, being tutored by fantastic faculty, and I have to say they were absolutely superb.  

But also the thing about the Change Academy was that it allowed me to join a very, very inclusive community of practice. And that wasn't something I didn't have, this huge amount of peer support at the trust, but I had this national level community of practice and a real safe space to be able to share problems and share knowledge and that was really unique, something I wouldn't have had otherwise throughout the course of my project, to be honest. 

Matthew Taylor 

So tell us more about the project.  

Llinos Jones 

So, as you've probably guessed from my name, I'm not a native English speaker, I'm a very proud Welsh lady. And when I set up a branch of the difficult asthma service in the area that I serve, I knew I was doing so to serve a community that didn't necessarily have English as a first language. 

Also literacy levels, in England, literacy levels, functional literacy's, not uncommon, one in six of our patients are functioning illiterate in Scotland, that's what up to one in four. So as I said, I manage asthma patients and that's a lifelong condition where you are asked to do a lot of self-management. 

The patients I was serving wouldn't necessarily be able to access a lot of the tools available for self-management. And seeing this sort of inequity, it didn't sit very well with me. I didn't want to be complicit in that. So I got a grant through the A Pathway Transformation Fund to develop a suite of multilingual resources that weren't written, I decided to do them with videos and QR codes. And so that was part of the project.  

And the other thing I did was I developed training for community champions. So we worked with local communities throughout the project. It was very much everything we did was co-designed with our local community. 

And what we developed was hopefully sort of very accessible, very relevant, but also very culturally competent, because we involved our patients right from the start. And with the community side, it was about spreading the messages at grassroots level and the results from that was very humbling.  

And we also developed some prototypes for graphic medicine information as well. Sort of transcending language altogether. So there are three parts to it really. And it's gone on to, to do very well. It was in a very, very interesting and very, very rewarding experience in my career to do this project.  

Matthew Taylor

And anyone who's ever been on a kind of change journey knows that that journey is like walking through hilly countryside. 

Sometimes it feels you're walking downhill with a sun at your back and it's great. And other times it feels that you're walking uphill into a gale. What were the biggest challenges that you found on the journey?  

Llinos Jones 

Gosh. I mean, there were quite a lot really. I was very, very lucky to be supported by the Health Innovation Network. I was very lucky to be supported by academic colleagues at the University of Huddersfield and also fantastically supported by the community I was serving.  

But I think one of the biggest challenges with any project like this is, as I mentioned, I'm a respiratory consultant, so we were just recovering from the pandemic and being asked to build back better. So time and resource was a real, real challenge.  

And I think at different points in the project, we faced different challenges. The nice thing was with a change academy, I genuinely had colleagues who could unblock me at different points along that journey, and I think that was really unique and very, very, very powerful. 

At any point, if there was something I wasn't sure of or wasn't sure how  to progress with, I always had somebody to draw. From a perspective of their own experience and a really approachable faculty as well.  

Matthew Taylor 

Well, that takes me to Richard, our faculty member. What do you think it is about the Change Academy that means that it stands out from other support offers that might be available in the NHS? 

Richard Jones 

I think the timing is very practical in that busy people can't necessarily take time out to do complicated leadership development and change programmes, but this level of commitment is not high and relatively easy to build into your clinical work. And I think the second thing is this ability to build on the change model I mentioned with Kotter as time goes by and it really gives people that roadmap.  

It's also very difficult to come across funds these days in the NHS, which won't be any secrets to anybody. So this is really a very welcome partnership with pharmaceutical industry. We've signed a Concordat, I think the NHS some time ago with the pharmaceutical industry who were keen to have a better relationship with their biggest customer, and this is an attempt to do something very practical, not related to any particular medication, but something that's of very practical use to clinicians. 

Matthew Taylor 

Yes. Well, I'm going to come back to the context in a moment, but Llinos, tell us a bit about the outcome of your project?  

Richard Jones 

Sure. Well, just after the last learning cafe, which is something we did throughout the course of the the Change Academy, we launched our QR poster with suite of videos about self-management of asthma, and it spread very, very quickly. We were absolutely blown away.  

The poster itself initially had ten different languages. With a bit of funds we had, we grew that to 15 languages, including British Sign Language, and it spread very quickly across channels and across actually continents.  

So the first initial drop had 65,000 views and then it was reposted and reposted, and we tracked it was put up in clinics as far away as New Zealand.  

We had thousands of people view the videos in different languages, which was really humbling. We had great support from national bodies in terms of spreading and scaling this. And we had a remarkable response to the actual video launch and then the community champions - I mean, I've just trained the third cohort, so that's actually been sustained very organically.  

And actually, do you know the thing about the community angle, like I said, we were tight on aims, but very loose on methods. What we learned a lot from the community as well, but actually we saw a lot of very humbling results from training the community champions, and actually some of the community champions used this as a stepping stone to gaining employment. 

So that was really, really lovely. So a lot of the outcomes from that were things that we hadn't predicted and has most definitely been sustained. So, yeah, those are the main things I wanted to mention.  

Matthew Taylor 

Well, brilliant. And I was going to ask you about this vexed question of how it is we replicate rollout, spread good practice. I mean, no conversation about innovation or improvement in the NHS will last more than five minutes before people bemoan the challenges of spreading good practice. You clearly cracked that in relation to your project Llinos, but Richard, more generally, how do you see this challenge of spreading good practice? Is that even the way in which we should understand the challenge? 

Richard Jones 

As I sort of alluded to earlier, I think we need to foster an environment where everybody feels as if they can make change within the NHS. The best example I could give of that was the Virginia Mason Hospital that you'll have no doubt heard of in Seattle. Virginia Mason, going back probably about 20 years ago now, was about to fail as an organisation and they adopted a model of improvement based on the Toyota Lean Model, and they are now consistently the top, most productive and safest hospital in the United States. 

And one of the features or the biggest feature of that hospital when we went - we were lucky enough to go and have a look - was that everybody has to have a change project. All employees, no matter what they do, what an amazing thing to see. And if you can make everybody feel as if they could improve things within an organisation such as the NHS, that's got to be the way forward, we can't do this in a top-down way. Sure, we can have direction and targets and names and so forth, but we really need people who work within the service to be change makers.  

And anybody who touches the NHS or works within it will be aware of waste. If you have a waste conversation with anybody, they'll identify within moments, areas where things could be done better, more productively, and save money. 

So having the initial conversation about where's the waste and then knowing how to go about cutting the waste and improving things, I think should be kind of the way we all do business all of the time.  

Sadly, far too often that there's a bit of a disconnect between those who can see the opportunity for saving money and those, perhaps just too diverted by trying to keep the business running.  

Matthew Taylor 

So, Llinos, when you think about your colleagues, the people you've worked with in your career, you must be aware, I guess, of the fact that for many of them embarking on a process of change feels daunting, it might feel intractable. 

What do you think we need to do to spread that sense of agency and possibility that Richard's just spoken about?  

Llinos Jones

Well, I think I felt quite overwhelmed, to be honest with you, starting off with very little experience of doing something like this. I think as time's gone on, things change, organisations change, structures change and what's been really lovely is having, which wasn't there when I started the project, but we've got real links with the local university, a director of innovation’s been at appointed at the trust. And I think change isn't easy but one of the things I learned actually the Change Academy, was that it's really important to have, not only community of practice, but important stakeholders that you can draw on throughout your journey. 

And I think that some of the challenges are surmountable if you've got support around you. And I also think that being given time, so where I was really lucky was I had a really supportive chief exec who, as the project went on, recognised the benefits of what I was doing and sort of was allowing me to have time to do it.  

And I think, just that permission to be able to have a bit of time off and concentrate on something that you really need to do and having something that can enable that to happen has been really, really useful. Because otherwise you're doing it on top of your work, on top of managing a family. I was up till sort of half past one in the morning, so many evenings a week for the, the duration of it. But having certain enablers within your organisation is key I would say.  

Matthew Taylor 

Yeah. When speaking of enablers, Richard, I'm speaking to leaders all the time at the moment who really face the most incredible pressures. 

I spoke to a hospital leader this morning who has to take £2 million a week out of her budget, over the next year, across the whole of the year. How is it possible to think about change or how should we think about change in these kinds of circumstances? I guess on the one hand, as you said about waste, well, there's no better time. We have to do things differently. We have to reimagine things. But on the other hand, what has just talked about a chief executive who gave her the time and the space to be able to focus on that. Well, time and space and money are all in short supply.  

So what's your message to leaders about how it is they can encourage people to deal with the incredible pressures that we now face in a way that gives the agency to imagine doing things differently rather than just kind of salami slicing stuff. 

Richard Jones 

Yes. I mean incredible pressures our managers are facing. Some of the most dedicated people I've worked with in the NHS come from the management community, their willingness to go the extra mile is often humbling. And when faced with such astronomical targets, like 2 million that you just mentioned, heaven knows where to start. 

Maybe if I could just bring it down to a sort of close to cardiology, as an example. This again, repeating the theme of go and speak to the front line and say, where's the waste? What can we cut?  

So if you come into a hospital with a full-blown heart attack. Then you are treated by the ultimate lean process: 

The ambulance brings you straight to the department of cardiology, straight into the cardiac catheter lab, which is where the value adding step is. Your coronary artery, which is blocked, will be unblocked, and you will go home often within the couple of days, two or three days, which is typically was six or seven days before. 

So there's a huge saving there as well as quality of care is much better, outcomes are better. So that's an example of a really very good process that's driven by time.  

If, on the other hand, you come in with a threatened heart attack, in other words, your artery is nearly blocked, but not quite, then we do what so often happens in the NHS, we start the medication to stop you getting any worse. But then we make you wait. And often the wait to go to that value adding step. The stent in the cath lab can be measured in many days and sometimes weeks, and there's plenty of data to support this up and down the country, but we have the facilities, we often have the staff, but we somehow don't connect the need to flex our system in such a way that we can get the productivity out of the, the cath lab systems. 

That's one, just one example of one pathology. And I'm sure if you were to have those conversations as leaders with many other specialties, you would uncover possibilities. The other, of course, huge challenge that we face and that creates a massive cost in the system at the moment is the disconnect between social care and the hospital. 

In my own hospital, where frequently above 200 medically-fit patients. And if we could unblock that as, as Mr Streeting has promised to do, that will hugely save, will improve throughput, and save money.  

Matthew Taylor 

And Llinos, what would you say to colleagues under the kind of pressure that I've been discuss discussing there with Richard to kind of help them with, one doesn't want to be insensitive to the pressures that people are under, but I guess in a way, my philosophy has always been however difficult things are, there are always choices to be made. There are always better and worse ways of doing what you're doing.  

Easy to say, but hard to kind of create that sense of agency.  

Llinos Jones 

I think so. But do you know, I've been very lucky. I've been asked to speak at various events nationally in the last few years and what I say to people is I'm very enthusiastic, I don’t want to overwhelm people - I'm very passionate about what I do in terms of trying to address health inequalities and sort of really genuinely want to empower patients to help them to self-manage a lifelong condition. But I understand that I can sort of overwhelm people by just, you know, my story.  

But what I say to people is very, very carefully, I say, look, everybody can do their little thing and it doesn't feel like a little thing to your patients. We can all adjust things and more things. And just that one little thing can perhaps make a huge difference to the patients or the people that you're serving or the staff that you are working with. And you can see people sort of beginning to, the cogs starting to go when you say that. And people have come up to me after and said, you know, thanks because actually just tweaking this or doing that, it didn't feel like much, but now you've mentioned it actually, I feel empowered to do a bit more. 

And I think there is something around trying not to overwhelm people with this huge story and this huge amount of work that I put in and just say, look, just do your thing. There's something all of us can do, no matter how large or how small that can initiate change for the better and hopefully inspire people.  

People often say that the talks are inspiring, but hopefully that that'll make people just feel as if they can and enable them to start their own journeys in a way that's accessible and very real for them.  

Matthew Taylor 

Thank you. Richard, is part of this recognising that different change processes are needed for different kinds of initiative? 

Now in the Change Academy, there are a whole range of different ways in which people want to do things. So for example, in some areas, engaging patients is a really important part of the process. It might sometimes be slow. It might mean you have to slightly change what you are planning to do because it might be the patient say that what matters to them is not the same as what matters to you as a clinician or as a manager, for example.  

In other areas it's less important. In some areas, we can kind of say there seems to be one best way of doing things; in other areas because of differences in local circumstances and needs and legacy, there are lots of best ways of doing things. What you need to focus on really is core principles. 

What's your perspective on that, Richard? And to what extent is one of the advantages of the Change Academy that because you've got a whole number of people in the cohort doing different kinds of things, it enables you not just to think about change, but also different ways of approaching change depending on what the challenge is. 

Richard Jones 

Yes. You're quite right and Nigel Crisp in last week's BMJ makes that point - in an organisation where most of your costs are staff, things like Lean Six Sigma change methodologies are not really as effective as relationship building. So when you're thinking about change, it's really important to know that you are changing the right things. 

You have to be very clear as to why is this urgent, why is this important to patients? Why is this important to organisation? If you can link your change for a positive outcome for the patient to have positive outcome for the finance director. That's probably going to be pretty important change, and that that comes on to sort of what Kotter would say - what is the burning platform? Why do we need to change?  

Well, at the moment, one of the big overriding burning platforms is of course, the money and the huge waiting lists. Although things are, I think, going in the right direction, certainly in my organisation, some really promising improvements.  

Second, you can't do this on your own. You need to build the guiding team. So with any change, think about who is going to be part of your team to help you achieve this. And simple way of thinking is anybody who touches the patient pathway from commissioner through to perhaps palliative care. Everybody needs to be involved in that.And then they need to create the vision as to how are we going to make this happen?  

And that simple Trinity, when you think about change, are we in this organisation aligning what we tell people to do with what they think the right thing to do is with what is actually going to work for them as people? We often don't ask that really, really basic question, and so often, for example, you go into organisations and what people are being told to do doesn't really align with their values, and then that causes all sorts of problems, or what people are being told to do doesn't really fit the day-to-day choices that they have to make in their jobs. 

So I think that would be my second thing. Let's start with the core human motivations, and let's try to make sure that change ticks all the boxes in terms of what drives us.  

So, I'm very grateful to you, Richard, for asking me for my view of change.  

I've got two last questions, one for both of you. 

Let me start with you, Llinos. Is Changemaking a habit? Have you carried on being a change maker?  

Llinos Jones 

Absolutely. It was just one of the most rewarding things that I've done. I've taken a bit of a break for a bit because I think it's really easy to get burnt out, and I was certainly feeling close to that after the project and managing a full-time job and the family and everything else. 

So I think, you've got to do it carefully. But once you've affected change and done so sustainably and at scale, it's hard then to go back to not doing anything. And like I've said in an earlier statement, I think if you notice something that isn't working, that isn't right and you don't try and change it, then you are complicit, aren't you? 

So I have absolutely carried on doing some change. But I've learned a lot along the way as well. And I think that there is a point where you have to say, I have to put my own oxygen mask on and take a break and do it in a sort of steadier way.  

But then, you know, you live and learn and one of the things that drives you to carry on as well is seeing the difference it makes to the patients. 

And that's really been wonderful for me. I can have conversations now in my clinic. I don't feel as if I'm giving a lack of equity of care. There's less distributive injustice in my clinic, I hope now, because I can give people the information that I want them to in a format and a language that's accessible to them. 

So I absolutely want to continue and I absolutely want to maintain that sense of usefulness and reward. But I've learned along the way that I have to do that steadily, otherwise I'll go under. So yeah, I've learned a lot and will continue to carry on in my journey in change for sure. 

Matthew Taylor 

Richard, Llinos, this has been an inspiring conversation, but it's really important that people have listened to this and they've had their appetites wetted to be change makers, that they know how they can get involved.  

So, Richard, where can NHS healthcare professionals, other decision makers that represent NHS healthcare organisations, where can they find out more information about the programme, including applying to go on the journey that Ilinos has so eloquently described? 

Richard Jones 

Yes. Well, everybody is welcome. Anybody who wants to change things for the better for patients is welcome. Another reason the academy is different is that it's taught by frontline clinicians, managers, nurses, as well as people from the Health Innovation Network and academics. So, these are people who are used to working at the front line, used to problem solving, really can understand the obstacles and the challenges that delegates face. I think that the delegates find that a really energising and inspiring group of people to work with.  

Email Pathwaysuk@astrazeneca.com and someone be willing to respond to you.  

Matthew Taylor 

That's great. And you know, we'll do this podcast again next year and the year after that and maybe we'll find someone who says, well, the inspiration was listening to Health on the Line. You never know.  

Richard, Llinos, thank you so much for joining me.