The One Year On update to Can Gerry Robinson Fix The NHS makes for interesting viewing for anyone who wants to see the NHS – or any other big organisation for that matter – change for the better.

Returning, Gerry saw some good things – such as the better use of the theatres – and less good things – such as the archaic paper records system and a feeling the consultants were still running the show.

What is clear from the programme is that glacial change and resistance to new strategies seems to be common. And we know from other research that this is true in commercial firms and public organisations around the world. Why is this? And can academic research throw any light on the subject?

Well it can; but like any other real-world problem, the answer is a complex mixture of several issues. In this case, the NHS is demonstrating three fundamental barriers to strategic change that have been written about by many researchers.

Firstly, the barrier of communication.

Leaders often use the wrong sort of channels, compromising communication effectiveness for efficiency. Complex messages about contentious issues can't be communicated by simple one-way channels like an email, however long and carefully worded. When they are, recipients don't understand and the message is lost in the competing "noise" from office gossip and, in the case of the NHS, the media.

The original series of programmes showed that communication, especially between managers and clinicians, wasn't working well. But a year on, communication at Rotherham seems to have improved, partly as a result of the CEO getting out there and talking to people. Sadly, communication between the hospital and the Primary Care Trust still seems, to me, to be poor.

Secondly, the barrier of culture.

Big organisations don't all share the exact same culture. Clinical staff often have different values and beliefs from, for instance, commercially trained managers or accountants. When the instructions of one group conflict with the values of another, passive or active resistance occurs and acts as a brake on change. We saw a lot of that in the first series.

The only way to overcome this is for each side to understand the others' beliefs. Rotherham seems part of the way down this road, but still has a way to go. Interestingly, part of the success has been achieved by giving consultant surgeons some management responsibilities. However, as is often the case with cultural clashes, there have been casualties and the NHS has lost at least one good surgeon who couldn't live with the cultural clash any longer.

Finally, the barrier of self-interest.

Like it or not, we all act in our self-interest to a greater or lesser degree. If a new strategy appears to compromise our interests, we at best lose motivation and at worst work against the new ideas. This holds true even for the most altruistic of us.

We saw this in the surgeon who found that doing more operations actually made him worse off. The only solution for this is to align the self-interest of employees with those of the organisation. That however is a tricky thing to do and, as Gerry discovered at Rotherham, the self-interests of various groups of employees often conflict.

These three barriers aren't mutually exclusive. Gerry Robinson's study of Rotherham Hospital provides an example of all three acting at once. The barriers are especially powerful when, as with skilled clinicians, the changes required by any new strategy are of the intangible sort that can't be measured - things like changes in attitude or habits.

So, in the face of three powerful barriers to change, what's to be done? Management research has some answers, but no panacea, to these issues.

The first step is to understand which of the three barriers are most important in your organisation. The solution then involves focussing on the barriers in order of importance.

If communication is the problem, the answer lies in reassessing the message, the audiences and the channels. Typically, more conversations are needed and less emails. Rotherham's CEO, Brian James, certainly has learnt that lesson and the results were great to see.

If culture is the problem, the answer lies in identifying the conflicting values between the different groups involved. Until those values are reconciled, at least partially, no significant organisational change will be possible. It's proving a long journey, but the clinicians and managers seen in the programme are beginning to respect each others' values.

If self-interest is the problem, the answer lies in redesigning structures and incentives so that the changes work with, and not against, the self-interest of those that have to make the changes happen. This is beginning to happen in Rotherham, but the programme highlighted a new review of the NHS that threatened to undo much of the good that had been done here.

In reality, these three approaches may need to happen all at once and change is hardly ever both fast and effective at the same time. That was amply summarised by Gerry Robinson when he said "You can't just introduce policy, it has to be managed."

However, the lessons learned by Rotherham Hospital, and reflected in the research literature about strategy implementation, can help the NHS - and other organisations change for the better.

Taking it further

It's all gone wrong: Why strategy implementation fails
Brian D Smith, available free [registration required] from www.pragmedic.com

Work And Motivation
Victor H Vroom, Wiley

Employee Commitment and Support for Organisational Change: Test of the Three-Component Model in Two Cultures
JP Meyer, ES Srinivas, JB Lal and L Topolnytsky
in the Journal of Occupational and Organisational Psychology 2007;80(2):185-211

The Corporate Culture Survival Guide
Edgar H Schein, Jossey-Bass Inc

Content last updated: 28/11/2007

About our expert

Dr Brian D Smith is a Visiting Research Fellow in the Marketing & Strategy Research Unit at the OU Business School. He has worked in the medical technology sector for almost 30 years. His research interests are in how firms make and implement strategy in practice, and this has branched out into his published works, Making Marketing Happen (2005) and Creating Market Insight (2008). These cover two areas: firstly, how firms make strategic planning work in the real world and secondly, how they make sense of the market environment to create market insight. His latest research examines what prevents firms from implementing their strategic decisions effectively.

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