In ‘Can Gerry Robinson Fix The NHS?’ we see a series of attempts to tackle some long-standing problems in a hospital. Many of these problems are common across the whole health service. Some of the problems highlighted in the first programme of the series include:
- Problems in working relationships between different professional groups
- Tensions between clinical and management lines of authority
- Underutilisation of operating theatres
- Poor coordination between different areas of the hospital leading to delays in patients getting to theatre
- Lack of an integrative management structure to actively manage performance
"why haven't these problems been fixed before"
As we are introduced to these issues for the first time, we wonder not only about what success Gerry may have as the story unfolds, but also why haven't these problems been fixed before. This is not just an issue in Rotherham General Hospital, but also in many large organisations; they find it very hard to change established routines in response to new challenges.
I am going to take a little time to discuss some of the things we know about what makes change hard. Here is a health warning: I am going to use two quite academic ideas. I do promise though to explain them in plain English.
Here is the first one: ‘the social construction of reality’. What on earth do I mean by that? Well, if I drop a rock, it is going to fall, quite possibly on my toe, whether I believe in gravity or not. However, many of the facts which I know to be true are social facts; they are only true so long as enough people believe them.
For example, if I go into a building and hand over some pieces of paper in exchange for a cup of coffee and some metal discs, we will all probably understand that I have bought something using ‘money’ in a ‘café’. Money though, only works so long as we all believe in it. Indeed there are plenty of examples in history of belief in money breaking down. The idea of a café is another social fact. The same is true of many of the facts of our daily lives; they are only facts so long as we have a shared set of beliefs. These self-perpetuating clusters of shared beliefs are referred to as ‘institutions’ by sociologists (that was the second idea!). They are the taken for granted shared ‘facts’ that we need to function in our daily lives.
The organisations we work in are full of institutions. Some examples from working life in hospitals might include: the hierarchical working relationship between doctors and nurses; the strict division of work between different kinds of staff; the idea of ‘doctor’ and ‘nurse’ and ‘patient’. These are all taken for granted assumptions that underpin the ways in which people work together. They are supported by a depth of history and active systems, such as the royal colleges which regulate the work of doctors and nurses, by the nature of professional training, even by the games we play as children. They are very important, because without some shared assumptions we would all have to continually start from scratch in working out how to cooperate on a piece of work. They are useful because we don’t need to keep questioning them; but that can also be a problem.
"often we see large organisations are perfectly adapted to manage the challenges they faced 10 or 20 years ago"
Back in 1982 Tom Peters and Robert Waterman wrote a best-selling book, “In Search of Excellence”. They identified a set of world-class, high performing firms; and set out to describe what made them different. They described these firms as all having a strong culture. Another way of putting this would be that they all had strongly institutionalised approaches to ‘how we do things around here’. However, in the wake of the book’s publication something very interesting happened. Many of the ‘excellent’ firms began to run into trouble. Strong institutions can make you very effective at doing what you have always done, but when the environment or the challenges you face change, all those taken for granted ways of doing things can get in the way of changing fast enough. Quite often what we see is that large organisations are perfectly adapted to manage the challenges they faced 10 or 20 years ago.
There is of course another implication. If changes to working practices are to last they need to be institutionalised and become part of the fabric of the organisation. How might this happen? To return to Rotherham, how might any changes that Gerry brings about be made to last once he leaves?
In the diagram below, we see that identifying and beginning new working practices are only the first steps in a change process. Much of the real work is in winning people over to seeing new approaches as legitimate and then establishing those approaches as taken for granted.
Adapted from Reay, Golden-Biddle and Germann, 2006.
"this work requires champions of change"
Those involved in introducing new working practices need to be alert for any opportunities to introduce these new practices; especially where it might lead to quick or easy wins. They need to find ways to integrate new practices with existing systems and they need to look for opportunities to prove the value of new practices to others. This work requires champions of such changes, not only to understand the technical details of new practices, but also to work through social networks and engage in the daily politics of organisational life.
Reay, T., Golden-Biddle, K. and Germann, K. (2006) Legitimizing a new role: Small wins and microprocesses of change. Academy of Management Journal, 49(5): 977-998.
A good discussion of the ‘social construction of reality’ and ‘institutions’ can be found on Wikipedia.
Find out more about institutions and decision-making in organisations in this free short online course (written by the same author) taken from our Masters in Public Administration and MBA.