Lead and manage change in health and social care
Lead and manage change in health and social care

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Lead and manage change in health and social care

1 How do you handle change?

Change comes in a variety of guises, and the way we approach and handle it differs from person to person. In Activity 1, you will hear two managers talking about their experiences of managing change, before moving on to explore your own approaches to change.

Activity 1

Timing: Allow 45 minutes

Start by watching these videos of managers in health and social care contexts. Anita Rogers was chair of the Ceredigion and Mid Wales NHS Trust, and is now a member of the ‘Save Aber’ community action group, campaigning to save local hospital services. Vivian McConvey is the chief executive of VOYPIC (Voice of Young People in Care), a voluntary organisation in Northern Ireland.

Vivian and Anita talk about their very different experiences of change. As you watch the videos, make some notes on the key pressures for change they mention, and the ways in which they handled them. What words do they use to describe change, and what emotions do they express in response to their role as managers of change? Were you surprised by anything they said?

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Transcript: Video 1

Narrator
This film is about the lessons learned by an academic and senior leader, Anita Rogers, who has experienced two very different kinds of leadership. Firstly, as an insider within the NHS, and secondly, as an outsider opposing a particular aspect of NHS policy.
Anita Rogers
I gained a number of insights about power and leadership from both experiences, as chair of a formal designated leadership role in an NHS trust, and a very informal role as a participant in a community action group.
Narrator
Anita is a Canadian who settled in Mid Wales. Today, she’s a member of the Save Aber Group, defending the services of the local general hospital. But previously, she was a senior manager in the NHS, working on an organisational change which she eventually opposed.
Anita Rogers
What I discovered, at least in my experience, was that a formal role doesn’t necessarily give you an immense amount of power. Whereas, in this informal role, as part of a community action group to save the local hospital, I feel a lot more of a sense of power.
Narrator
Between 2006 and 2008, Anita served as chair of the Ceredigion and Mid Wales NHS trust.
Anita Rogers
My job was to lead the board of directors. In essence, it meant speaking to the press, speaking to the public, representing the views of the organisation. My job was also to chair the board meetings.
Narrator
The trust was one of 22 designed to manage hospitals across Wales. But in recent years, the Welsh Assembly has made moves to centralise clinical expertise and save costs by merging trusts.
Anita Rogers
During the time that I was chair, the plan was to merge administratively with two neighbouring trusts in the south of the country – Carmarthenshire NHS Trust and Pembrokeshire NHS Trust. The plans seemed like a good idea at the time because the promise was that we would run more smoothly, that we would have more access to trade of services, if you will.
Narrator
But in the rural Aberystwyth catchment of the Mid Wales Trust, there was deep suspicion. Locals feared the services of their only general hospital, Bronglais, would be downgraded if there were an administrative merger.
Interviewer
And when you were chair, which side were you on?
Anita Rogers
When I was chair, I initially believed the promises that an administrative merger was appropriate and that it would ultimately result in better services – that it would knock down the organisational barriers whereby doctors could go back and forth amongst the three hospitals that were going to merge. I really did think it was a good idea.
As time went on, staff were increasingly uncomfortable. They had actually been in a similar situation many years before. They had a long memory. And I began to see that, in fact, the promises were hollow promises. That there was going to be a danger of services being eroded here.
I should also say there wasn’t really a choice. This merger was mandated by the Welsh Assembly Government. And whether I had objected or not, it would have gone through.
Narrator
The potential problem for patients was that if services at Bronglais were downgraded, they faced an 80 mile trip to the nearest hospital.
Anita Rogers
For many of the health care treatments that they need, they will have to drive an hour and a half or two hours. And in Wales, the drive is on curvy narrow roads, so these are very difficult distances. In addition, there is the issue of the golden hour. If somebody is in very serious health difficulties, they have the best chance of surviving if they’re are treated within the hour – the golden hour.
Narrator
Despite her increasing concerns, Anita hung on to her role as chair, trying to exert influence from within.
Anita Rogers
There is very little evidence anywhere that mergers accomplish what they set out to accomplish – cost effectiveness, better services. They just don’t do it. There’s no evidence base they do. And I spoke out in the Wales community about my concerns.
The regional director paid a visit to me spontaneously. He just happened to be in the area, is the way I remember it and the way I remember him telling me how he happened to be there without an appointment. But he said, if I don’t toe the line, they could pull me out of there tomorrow. What was shocking, though, being in the role myself was that feeling of not having any power at all. And to this day, I’m still haunted by it.
Narrator
After the merger, the local trust and Anita’s role within it ceased to exist and a new centralised health board took over.
Anita Rogers
The fears of the local population and the staff at Bronglais hospital in Aberystwyth have come to pass. The hospital services have been eroded. There has been consistent removal of services from Bronglais and those services have been relocated in the south of the country, in one of the two hospitals with whom we originally merged. So there has been a centralization and a consolidation of services so that now the local district general hospital is actually in danger of not being able to survive.
Narrator
After her frustrating experience, Anita tried to join a local pressure group, which had long been fighting to save Bronglais as a fully functioning district hospital. At first, the so-called Save Aber group was cautious about her approach.
Anita Rogers
Joining the group was a really interesting process because I had been the chair, I’d actually met with this group, and at the time, I was on the side, really, of the health board. So I was seen, really, at the very least, as untrustworthy, or the enemy at worst. So it wasn’t easy to break in. It took several months to establish a level of trust.
Narrator
The voluntary group is made up of practising and retired health professionals, GPs, hospital consultants, nurses, and local politicians, and is informally chaired by retired hospital consultant, Peter Gartner. But although there’s no official hierarchy, some members are more influential than others.
Anita Rogers
In the Aber group, yes, it’s a collection of equals. But the leadership actually resides, to most extent, I think, in William Roberts, who is the one who coordinates, who has the vision, who has mobilised people, who has the political networks and uses them. So it’s not a positional leadership. Ostensibly, he is just another one of us volunteers, but in fact he has taken leadership.
William Roberts
If we’re asked about do we want cardiology or cardiac surgery in Bronglais, the answer has to be no. But if we want general surgery, it’s pretty clear to me that we want to say that.
Narrator
But William Roberts doesn’t set all the agendas. Despite the common aim of saving Bronglais, there are considerable disagreements over the details.
Anita Rogers
It’s one of the reasons why I’m a bit tentative to jump in, intervene, try to focus it. One, I’m not the chair, but two, I’m aware of the factions and the tensions and the kind of slots that people, I think, have.
Narrator
One long running tension is about how complex or simple the group’s public message should be.
Jack Evershed
My message is a very simple one. It’s always the simple moral one, that we have an equity, that there needs to be equity of access to services to the people in Mid Wales. And especially when it comes to emergency, we deserve the same right to life as anyone living anywhere else. That is a message that’s not hard to sell.
William Roberts
There are two plans. There’s your plan, Jack, which is quite different to the plan that the consultants came up with and which they prepared for Elin. And therein starts lying a problem.
Jack Evershed
Yeah. Well I still haven’t seen that particular document.
William Roberts
Well, I’ll pass it on to you.
Narrator
Another complexity is differences in the vested interests of the professionals in the group and their attitudes towards the new centralised health board, [INAUDIBLE].
Elin Jones
But I think the issue of consultation and now pushing the health board to accept that they have to get out there and talk to people otherwise they’re going to lose the argument and it’s going to be political mess, really.
Diane Richards
Unfortunately, it’s not just about talking to people, it’s listening to people.
Speaker One
What’s the feeling about other consultants in the hospital about this?
David Jackson
Certainly some of them, they’ve got their wives, their family, or they have to protect themselves in a way. And I think the health board would be unremitting in its treatment of various consultants who broke ranks.
David Lewis
I think that it’s only fair that we don’t lay all of the blame on [INAUDIBLE]. A lot of the change in practice has been imposed from Royal Colleges and other colleagues in the disciplines that we work in.
David Jackson
You cannot have half a hospital. You cannot suck away services that are totally independent.
David Lewis
I couldn’t agree with you more. I wasn’t implicating the status quo I think it –
David Jackson
– a lot more combative.
David Lewis
All I’m saying is that I’m trying to apportion how these unfortunate decisions have been made. And often by our fellow professionals.
Diane Richards
Also, going back to what you said about consultants are worried because they’ve got their families here. They don’t want to rock the boat. Consultants come from away. Nurses and all of the other therapies tend to be from here. And so they’re going to be defending their community to a far greater extent because it’s our family, our neighbours, and our friends.
Anita Rogers
I think the free-flowing style can be a little bit problematic because it gets a little unfocused from time to time. What we saw in the meeting last night was a paradox in that we had a group of, individually, very strong leaders who came together voluntarily to be in this meeting. Paradoxically, what we lacked was strong leadership of the meeting itself.
Narrator
Despite the lack of agreement on details, the campaign still flourishes because the broad aim of saving Bronglais unifies the group. And most of the work takes place in between the bi-monthly general meetings.
Anita Rogers
Most of what’s happening is going on behind the scenes. There’s a lot of networking that goes on – meetings with various public people, groups. But it’s very emergent, because opportunities come up. And I think that’s really a significant part of leadership – to actually be able to spot the opportunities as they come up and to take advantage of them. It’s important not to be defeated by what looks like formal authority and formal power. That there’s a tremendous amount of power available in local and emergent leadership.
Narrator
During the filming with Anita, we encountered another example of the significance of emerged leadership within the health and social care sector. There was a demonstration outside the hospital as part of the National Day of Action on Pensions. Just as with the Save Aber group, it shows that people can, individually and collectively, take a stand against the forces of strong organisations. They could also use their conscience, guided by moral vision of some kind, to lead in a variety of ways, both inside and outside of formal institutions.
Anita Rogers
One of the things I have learned about leadership over the years is that it’s a constant negotiation process. And there’s an ebb and a flow. There are constraints, there are budgetary concerns and worries – there are many different kinds of constraints that are real and that we have to live with. But for a leader or a manager in which, perhaps, decisions are being taken that they may not agree with, I think it’s very important for a person to weigh up in a vigilant way. To be vigilant, not morally blind, and continually examine the central purpose of why they’re there, which is care of patients. These are not easy issues. Ethical dilemmas are not easily resolved. Sometimes they’re not resolved at all.
End transcript: Video 1
Video 1
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Transcript: Video 2

Vivian McConvey
This is what a strategic plan of 100 pages looks like.
Narrator
Vivian McConvey is the chief executive of VOYPIC, of voluntary group with 36 staff based in Northern Ireland, which represents the voices of children in care.
Vivian McConvey
We started off with a consultation with young people. Then what we did was we consulted with yourselves long, long time ago. It’s taken two years.
Narrator
Vivian’s currently leading a strategic review of VOYPIC. Today, she’s discussing some big changes with one of four regional teams.
Vivian McConvey
Because I’m living and breathing this at the minute. But how do I get from my bit of living and breathing it down to your bit of really understanding it.
Narrator
Vivian now has a fairly assertive leadership style. But 10 years ago when she took up the post, her first as CEO, she felt uncomfortable.
Vivian McConvey
It’s quite a step up to go from senior professional adviser in an organisation to chief executive, and I always looked at myself as a baby chief executive. I was really doubting all the decisions I was making, even the confidence of lifting the phone and saying, ‘Hello, this is Vivian McConvey, I’m the chief executive of VOYPIC.’
It takes a lot of confidence to sort of make those cold calls, develop those relationships. And I went to the board, and I said, this is a whole new post for me. And I need to make a shift in my own mindset.
Narrator
Working with VOYPIC’s board of governors, Vivian was helped by a series of mentors to assist her in developing a leadership style.
Vivian McConvey
What’s really clear to me is that the learning is ongoing. And also, I maybe made less mistakes because if I’d gone in gung ho feeling like I had to be this type of person, I might have not taken enough time to really understand what impact I was going to have on people, what the relationship was going to be. And so what originally felt like a negative because of a lack of confidence, it actually was a really good process.
[Phone ringing]
Speaker One
Good morning, Voice of Young People in Care. How can I help you?
Narrator
VOYPIC represents young people in care through projects that offer advice and opportunities. But Vivian’s review has highlighted a need for fundamental change. A key finding was that children were being consulted too formally.
Vivian McConvey
These children live in a system. And we got into very sophisticated consultation mode, as opposed to they’re with us every day, and we should just be talking everyday. Do you talk to your kids everyday? About everything that’s going on? Everything?
Speaker Two
Yeah.
Vivian McConvey
You don’t say, I’m gonna sit down tonight and consult with you.
Speaker Two
They would run out the door.
Vivian McConvey
They would. So what are you doing with your kids?
Speaker Two
We need to talk to them. We need to have that conversation with them. We need to listen to them.
Vivian McConvey
Yeah, we need to find a clever way to constantly have a conversation. So the first thing I want to do is, I don’t want to hear the word consultation anymore. I really honestly don’t want to hear it.
Speaker Three
The thing about it is, for me, consultation is you’re nearly consulting the same young people over and over. If you’re having the conversation, you tend to have it with other young people who you’re working with because I’m thinking about the group that comes into the office, they’re your first port of call. But the conversations can be much, much wider.
Caoimhe
Donna had said, as well, about that we’re tapping into the same group of young people all the time, the ones that’ll say, I’ll fill in that questionnaire for you, I’ll come to that meeting, I’ll do the consultation. But then you’ve got our young people who maybe that word or a questionnaire or interview questions, and they kind of panic. And they don’t want it.
Vivian McConvey
What I’m looking for is a conversation about children’s lives. It’s integrating into every staff member. Behind you will be a policy unit that will give you the questions. You’ve got the skill and the professional competence to know how to do that and have that conversation with young people. You bring it back in.
Narrator
Over the years, as Vivian’s confidence has grown, she found a need to develop further leadership skills, especially being able to hold back a little.
Vivian McConvey
Yes, I do control my style because there are things about me that I know can be quite scary around other people. And some of the things that can be scary for staff is if you are a quick thinker and if you’re very chief executivey, you’re very outcomes focused.
So what I have to control in working with my managers and staff is that I know the outcome that I want to get to. I have to pace it at their pace. I have to understand how far they’re coming along and where we’re going to. And, therefore, I have to curb and control either my fear the project’s not going to be completed, or my excitement and get really involved in it, or the challenge that I have in wanting it really done by my time scale and not listening to the messages that I’m getting from everyone else.
Narrator
Another finding of Vivian’s review is that services are not matching the needs of some service users. The solution is to reorganise VOYPIC’s specialist programmes, currently stretched across Northern Ireland so that, instead, they’ll be covered by every regional office.
Vivian McConvey
This is a big change for you. So where you were reporting Eileen to Mel, that’s not going to happen. Where your focus is so participation, that’s not going to happen. Where you guys are so focused on the mentoring, that’s not going to happen.
Caoimhe is leading up mentoring. She’s going to be trained in participation. And she’s going to be trained in advocacy. And she will be the manager of all those services and doing all those things. And that’s a big change for all of us to make because we’re going to have to have flexibility, guys. We’re going to have to put our shoulder to the wheel and help each other and do these things. Any fears? Loss, anxiety?
Speaker Three
I’m gonna miss Mel. [LAUGHTER] I’m gonna miss my manager. But, sure, I’ve got Caoimhe now. But I’ll miss the participation team and all that involvement.
Speaker Four
I think that’s a fear for everybody. And me, as a manager too, I’ve been on the mentoring service for five years.
Vivian McConvey
We need to pay attention to endings. There is an ending here coming up. And something has begun. And how do you manage the transition in between? And if we don’t pay attention to endings, you don’t say goodbye to that sort of stuff and then open your mind up to, well,there’s a new way that I have to be.
Narrator
Vivian’s experience of management and leadership has also steadily improved her ability to employ the right skills for each occasion.
Vivian McConvey
If I was really honest, I’d probably say that I was very uptight and conscientious coming into management. In that sense, I was probably like Delia Smith.
You know the recipe. There’s a procedure. Fill measurements. There’s a way to do it. And you get the same result every time.
But you don’t sort of go off-piste. And you don’t sort of try anything. Now as a manager, I’m probably more a bit like Jamie Oliver.
You know the fundamentals. But you know that you can change in many ways. And you deal with things very individually. And you’re much more relaxed about it. It’s a glug of this, a dash of that. You can actually enjoy what you’re doing. And your relationships are different.
Narrator
The following day, Vivian has a new challenge. She’s about to meet some of her senior managers to help her lead the forthcoming strategic changes.
Vivian McConvey
What I’m looking to do here is actually to build the skills and the leadership role of all of the people sitting down around that table. What I’m trying to do is to say that I’m not the only leader here, that what I need is that everybody around the table is a leader in their field.
Narrator
A key aim of the meeting is to start creating a timetable for the changes she wants to bring in over the next three months.
Vivian McConvey
Think about it from your perspective, first of all. Where do you see yourself in this? What’s a type of reasonable time scales?
Imagine it like a big field. Right? With nice firm boundaries around it. I’m not going to tell you what to do in that field. You have to actually grow that yourself.
What I’m trying to do is get the collective intelligence around the table, to get it all together. This is going to be a living document. It’s a bit like a strategic plan. It’s a living document. It’s going to be there. And it nearly needs to be our handbook to help us.
Narrator
For the first part of the meeting, Vivian sets the managers the task of making notes about their specific responsibilities. She’s also looking for ownership and a sense of urgency.
Vivian McConvey
I want to start to put by when. So then you’re going away from here today in your diaries and saying, I thought of some piece of work I have to do. And I also go back to the other thing is, you can’t have people in transition too long because they begin to lose the focus.
Narrator
But even the best laid plans don’t always run smoothly.
Vivian McConvey
So in each bit of this, what we have to do is make the linkages in the process.
Jillian Houston
I’m not here.
Vivian McConvey
I know you’re getting married.
Speaker Five
When’s your last day?
Vivian McConvey
24th.
Jillian Houston
No, that’s the day of the wedding. 20th, 21st.
Vivian McConvey
Right. This is where it’s going to be serious. What I need you guys to do is you see when we’ve got these activities, you have to begin to think, what’s my diary between now and next June?
Jillian Houston
Can’t happen, because this is the problem, and then people’s back in and all this – no.
Vivian McConvey
OK. Well the other thing –
Speaker Six
Do you want to rush things? You don’t want to rush something, if we’re really going to do this new modelling, new practice and way of working then we need to pilot it.
Jillian Houston
But then if I do those three days, those – oh no, that’s St. Paddy’s.
Vivian McConvey
This is where I need you to have your diaries. You have to seriously look at this timetable and seriously begin to think because somehow, in our head, we have to have the big picture map and in the box that you’re in, because where I’m going with this, in these activities, how I’m going to do the next bit of this is I’m going to have a calendar like a Gantt chart.
And what we need in a Gantt chart then is, when these activities are done, so we then look at that. But I can’t get to the Gantt chart or the calendar until you begin to fill these things out. And then we realise that, you know what, March has got 28 days. And we’ve fitted 40 working days of work into it. It’s not going to work.
Interviewer
Is there any danger that when you go through a big change like this, that the service user suffers?
Vivian McConvey
Oh, absolutely. And that’s why I have tried to emphasise the absolute importance of laying out a timetable and knowing when the switchover date is because the longer you prolong the change process and not moving into the new process, people will switch from committing themselves to work out what’s best for the service user to getting worried about what’s happening to them.
Narrator
But if Jillian’s wedding is not enough, VOYPIC’s head of finance is about to drop her own bombshell.
Vivian McConvey
Populate that. Anything else that we’ve missed in that change management process of either training, attending to anything at this point?
Karen Stirling
Sorry, Vivian, I forgot say to you, I’ve been called for jury service from Thursday the 5th of January to four to five weeks. They said I wasn’t allowed to leave the country.
Speaker Seven
Four to five weeks?
Karen Stirling
Mm-hmm.
Speaker Seven
That’s longer than it usually is now too.
Vivian McConvey
Which jury service? Which court?
Karen Stirling
Laganside
Vivian McConvey
So you’re at least in Belfast?
Karen Stirling
Yes, I can work mine every morning, and come back again, work late.
Vivian McConvey
OK. It is the best of times. And it is the worst of times. Well what’s going to have to happen, Stirling, is you’re going to have to start to think about when the salaries and wages are being done because you are the sole person who does that.
Karen Stirling
It is a real inconvenience, especially at the end of the financial year. I don’t know. What I’ll do is bring in all the forms and have a wee look at them, and if we can get a letter, it might work out.
Vivian McConvey
It’s really indulgent for a CEO if they want to kick things around a room and be really angry over something. And in Northern Ireland here we would have a saying called no back doors. So people would say that I’m very upfront, and there are no back doors. And I clearly say to them how I’m feeling about something.
It’s about understanding, controlling your emotions to a point that you’re not over emotional. Have the emotion, but it’s not that you become aggressive or angry because the other thing is people below you look to you for guidance.
End transcript: Video 2
Video 2
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Discussion

Vivian and Anita each describe very different change processes. Anita reflects on her experiences of trying to manage a large-scale organisational change, which she eventually came to oppose, while Vivian discusses the changes she experienced when she moved into a senior management position.

The experiences they describe highlight that managing change is both a professional and personal process. Anita describes feeling ‘haunted’ by a feeling of powerlessness she experienced in her professional role, and notes how she now feels much more of a sense of power as a member of the Save Aber group. Vivian reflects on her initial lack of confidence when she began her role as Chief Executive, and notes how she eventually came to see this as a positive thing as it meant she took a more considered and thoughtful approach to her management style.

Anita and Vivian’s experiences illustrate the often extremely lengthy process that change involves. Both stress the importance of bringing other people on board to help them in the change process. The video shows Vivian discussing upcoming changes with her colleagues, and the roles her staff will take during the change process. Anita talks about the importance of networking with other individuals and groups who have the power to support the Save Aber campaign.

Activity 2

Timing: Allow 45 minutes

Now complete the checklist, ‘How do you handle change?’ [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)] using the range of options to record how strongly you agree or disagree with a statement. When you have finished, choose two statements that you strongly agree with and two that you strongly disagree with. Then, drawing on your own experiences, write down the reasons for your views.

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Discussion

Anita and Vivian took very different approaches to managing change, but what their experiences highlight is the high level of emotion this involves. The change management checklist explored your own emotional reactions when faced with change. The statements you chose from the checklist will probably be closely linked to your own experiences. Reading through these statements, you may have been struck by how many related to the emotional impact of change and the importance of communication. Frustration, uncertainty and anxiety are just as likely to feature in people’s experience of change as feelings of excitement, optimism and commitment.

It is very easy for people to feel disempowered during a change process, and this is as relevant for people who use health and social care services as it is for practitioners. Of course, managers also experience heightened emotions during periods of change, but they are not necessarily permitted – by their own managers or by social conventions – to express these as freely as other colleagues. Managers need to take responsibility for their own feelings as well as supporting staff and services users through a change process, and that is why it is helpful as a manager to have an insight into your own approach to handling change.

In this section you explored personal approaches to change, and the emotions this can evoke. The next activity will help you to understand the pressures for change in health and social care contexts and will introduce some key ideas about change from organisational theory.

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