NHS change management

According to Jacqueline et.al (2004), Psychological contracts are individual beliefs in reciprocal obligations between employees and employers. In today’s continually changing business environment organizations have to change strategic direction, structure and staffing levels to stay competitive and gain advantage (Armenakis & Bedeian, 1999). These changes lead to a great deal of uncertainty and stress among employees (Terry & Jimmieson, 2003) which leads to resistance to change in the organizations.

Individuals in organizations resist change for a variety of reasons (Kets de Vries & Balazs 1999), for example, some ideas for change are simply ill conceived, unjustified, or pose harmful consequences for members of the organization. NHS is not an exception for this, they underwent resistance from employees during the course of change and this can be further explained using the coping cycle (Carnal C, 1986) that involves various stages.

The “Coping Cycle”

According to Carnall (1986), the problems of implementing change are resistance to change in people. He argues that the practical and positive steps are required to be taken to support people as they cope with change. He also explains that change creates uncertainty, anxiety and stress which will have impact on self esteem and in turn decline in self esteem affects performance.

To make changes happen at NHS, it has brought new system, processes and methods which have to be learned, and the modified system took time to progress because new systems did not work perfectly in the first round. As a result of this there was a decline in self esteem which led to resistance for change. The following five stages are those that NHS underwent during their course of change.

Source: Carnall, 1986

Stage 1: Denial

This arises as most of the people do not see benefit of change. Denial is also due to uncertainty for example job insecurity. People are flexible with the present condition and they fear that the change may bring problems and lead them to new training, learning new skills, change locations etc. In this stage self esteem goes up and performance improves to some extent as the people make efforts to show that existing system is good.

Issue: The system at NHS is today is totally different from 1980’s. People followed different pattern of behaviour at NHS. In earlier days they followed the behaviour of “I am Responsible”. Because of the changing government policies, technology advancement, interpersonal working has become the norm, quality, customer service etc.  “I” has become a problem and people started resisting (denial) the change (D Plamping, 1998).

Solution: Clear communication from top management about the change and need for the change and importance of it was introduced however the implementation was not carried out uniformly throughout the UK. It is required to communicate and show the importance of people for the organisation. (Department of Health, 2005)

Stage 2:  Defense

This stage is characterized by defensive behaviour. The realities of change become clearer and people should be prepared to face new tasks, working with new people, new boss, and different group of people, in a different department or a new location. People often feel that their hard work has note been valued which they used to defend their existing system. This can lead to feelings of depression and frustration among people because it will be difficult to work out how to deal with these changes. During this stage both performance and self esteem decline.

Issue: As the pattern behaviour “I am responsible” seems not fit for NHS because the change requires co-ordination and collaboration. People are required to interact with other departments, different people, mobility etc. All these concerns popped up and people started defending their behaviour.

Solution: This problem has been analysed by the white paper and proposal called "a duty of partnership" on all organisations in the NHS (D. Plamping, 1998) has been suggested. This proposed theory seemed to do more with ownership than collaboration and they come out with enhanced behaviour pattern “I am responsible in partnership with others”. This may bring working across boundaries more effective to build relationships and other sorts of management activity viable (D Plamping, 1998).

Stage 3: Discarding

“Discarding is initially a process of perception. People come to see that the change is both inevitable and /or necessary. It becomes apparent to them. Adaptation starts with recognition” (Carnall, 1986)

During this stage few people begin discarding and some early adopters come into play to take up the change, however most of people remain unchanged and feel threatened by the implementation of new changes.  For some people the new job assigned appears to be of lesser status, valued skills seem unnecessary, the new work appears to be frustrating and even frightening, and this is toughest stage that organization comes across. During this stage self esteem and performance is typically low as the process needs time to cope up.

Issue: Even after the proposal of new theory, many people are not convinced and they showed resistance for change.  Few people who are interested in change and discarded the resistance to prepare for the change.

Solution: NHS identified that effective communication was required to cope further at this turbulent zone (M Laycock, 2005). People involvement is required and changing to a new pattern of order may be achieved by engaging them directly. People who are involved are less likely to resist (D Plamping, 1998).

Stage 4: Adaptation

“Significant amounts of energy are involved here. Often the process of trial and error, of effort and set-back, and the slow building of performance, can be a source of real frustration. In these circumstances people can evince anger. This is not resistance to change. Rather it is the natural consequence of trying to make a new system work, experiencing partial, or complete, failure, which may or may not be under the control of the individuals concerned. This anger is not evidence of attempts to oppose but rather articulates the feelings of those trying to make the new system work.” (Carnall, 1986)

During this stage mutual adaptation emerges and people start to take up the new systems and methods and test themselves. The resistance will be very less, self esteem and performance starts to move up with the organizational change. This stage is the indication that change has started taking a shape. 

Issue: After involving people in the change, few people still shows resistance because of the time taken for the change. Adaptation requires much time as it involves trial and error process. This shows still people have some uncertainty about the future of the change itself.

Solution: Management may work on this and they interact with people for negotiation and mediation to create win-win situation. This win-win situation is a positive strategy that works well and can be used to process the required change (Thornborrow, 2008).

Stage 5: Internalization

People involvement is recognized at this stage. New relationships between people and processes have been tried, modified and accepted. Most of the people started including the late majority prepared for the change. Here the planning and implementation are effective and consequently self esteem and performance on the raise. “This is a cognitive process through which people make sense of what has happened. Now the new behaviour becomes part of normal behaviour” (Carnall, 1986).

Issue and Solution: Adaptation confirms the acceptance of people i.e. coming to the terms and accepting the change. Organization has to be more careful in executing the contract and keep the trust alive between them.  Failure to do so may trigger the resistance again.

Suggestion:

As the various stages explained, it seems that people at NHS  experienced change in these ways, initially as disturbance, perhaps even as a shock, then coming to the reality by acceptance, testing it  out and  involving in a process of mutual adaptation and finally, achieving it through the process of internalization (M Laycock, 2005). However it can still be argued whether all the staff at NHS have reached the internalization stage.

According to Carnall (1986), coping with the process of change places a demand on the individuals involved. Various issues need to be faced either by the individuals or by managers. Note however that these issues are of concern to all affected by an organizational change, including managers.

It is clear from the coping cycle that employer relationship is much more important in the process of psychological contract, effective communication and good relationship always gain advantage in the organizational context and people will be prepared for the change. We also insist NHS to adopt a frame work suggested by Guest (2008) for applying psychological contract to employment relationship in the organization to gain advantage and better performance.

5.1 Leadership Change

Importance of leadership to managing change:

When sustainable change initiatives are made, there are few essential attributes change agents need to develop like vision, courage, commitment to change etc. Managers should have the competence (possession of skills, knowledge and aptitudes) and effectiveness (in successful application of skills, knowledge and aptitudes) for completion of tasks (Thornborrow, 2008).

Kinds of Leadership:

Transactional leadership: a leader who treats relationships with followers in terms of an exchange, giving followers what they want in return for what the leader desires, following prescribed tasks to pursue established goals (Buchanan, Huczynski, 2007).

Transformational leadership: a leader who treats relationships with followers in terms of motivation and commitment, influencing and inspiring followers to give more than mere compliance to improve organizational performance (Buchanan, Huczynski, 2007)

Charismatic leadership: authority based on the belief that the ruler has some special, unique virtue, either religious or heroic. Religious prophets, charismatic politicians and pop and film stars all wield this type of power (Buchanan, Huczynski, 2007)

NHS Context

The need to develop and manage the future direction for public sector organizations is a difficult task, especially like a big organization like National Health Service (NHS) which is world’s 3rd largest employer. NHS went through reformation within the organization as malpractices, unnecessary deaths, and poor customer service was affecting them. Many of NHS physicians were opting for the private sector. A blurry sense of leadership within the NHS was leading to confusion internally, causing friction between staff and management. A clear vision seemed to be obsolete within the leadership which has led to uncertainty within the organization.

Management and leadership in health care involve an individual’s efforts to influence the behavior of others in providing direct, individualized, professional care. (La Monica, 2005). The aspect of leadership within the NHS has proved to be the most difficult challenge of the organization. In many trusts, chief executives and their boards are struggling with the “vision thing” – how to articulate and deliver a new pathway for their trusts which can be understood, communicated and implemented to ensure survival and long term growth for the organization and its key stakeholders. The NHS failed in establishing a clear and sustained vision, due to the inability to retain a figurehead to lead the organization. Robbins and Judge (2007) define leadership as the ability to influence a group toward the achievement of a vision or set of goals, which requires there be a vision in place before the leader can influence the organization.  Influencing activities must become central in order for effective change to flow throughout the organization; strong leadership will enhance this process.

In the context of NHS managers were struggling to deliver a transformational change. In trusts, the modern challenge must be based on managing resources to develop new services or partnerships and creating an environment in which stakeholders can contribute to organizational goals and are given discretion to achieve them. In NHS, most people were willing to follow and involve themselves in something when they feel a part of it. There was also a movement to invite private companies to manage the NHS services which proved to be an unsuccessful venture, and caused division within the organization. In the concept of the managerial role, the main priority is the accomplishment of the organizational goals. The private companies have little, if any, familiarity with the goals of the NHS, and as a result were not able to deliver services in a patient focused direction.

Recommendations:

We recommend a transformational leadership in NHS. Again coming back to the definition of transformational leader, it suggests a leader who treats relationships with followers in terms of motivation and commitment, influencing and inspiring followers to give more than mere compliance to improve organizational performance (Buchanan, Huczynski, 2007).

                                                                                                         

                                               Transformational leadership model

                                                    (Source: Thornborrow, 2008)

Why need a transformational leader?

The detailed review on why this leadership should be adopted in NHS is given below.

The leader’s task is always to manage difference and diversity and from those things to produce uniformity in terms of product and excellence in terms of service (Viney, 1997).Top managers should build consensus and motivate stakeholders to achieve the above in business. They should have an informal process of leadership, vision building, team building, communicating and commitment building. The excellent work of Synder and Graves (1994) on leadership and vision building defines vision and its delivery as a target towards which the leader aims their energy and resources. The constant presence of the vision keeps the leader moving despite the various forces for resistance; fear of failure; emotional hardships such as the negative responses from superiors, peers and employees or the real hardships such as the practical difficulties or problems in the industry. Vision is the force within the leader that spreads like wildfire when properly communicated to others. Vision refers to an image of the future that can be discussed and perfected by those with an interest in it … it is a glue that binds individuals together into a common goal. The methods NHS can adapt are as follows:

(Source: H. Mark, S. Peter (1996))

The development of a successful vision is critically dependent on a powerful competitive strategy in the marketplace which articulates the strategic framework around which the organization will operate. The development of strategy in NHS trusts to meet the new demands of the internal market is a major issue which many providers are still struggling to achieve as so often their approaches are replications of the past configuration of services. The involvement of these key stakeholders is crucial to the delivery of the strategic direction since they need to demonstrate consistent and visible support for the change. Reyneirse (1994) believes that the success of any organizational wide initiative requires the support of the chief executive and their top-management team and their continuing involvement in the change process. Importantly, the organization needs to consider its current position at a given point in time, hence the development of tools which are useful in determining an objective snapshot in time such as questionnaires, interviews with key managers, clinicians and other employees, and surveys can be good vehicles for gaining commitment as well as a clear view of the strengths and weaknesses of the organization. An understanding of the current pulse and temperature of an organization is important in the context of long-term change. Again, establishment of core value by top management is perhaps the most difficult process. In many cases, trusts and clinical directorates lack focus and their managers and staff can be confused about the wider organizational goals and targets and how these are to be achieved. Organizational values can also be achieved through participation and interaction of key stakeholders in the organization through events where chief executive, chairman, management team and senior clinicians will be attending.

Participation of workforce and individual employees is critical to the success of translating vision into reality. The work of Synder and Graves (1994) confirms that, in transformed organization employee is seen as a key stakeholder who wishes to exercise a significant influence and control on their part of organization to shape its future direction. Trusts must develop new forms of leadership which are centered on improved techniques to communicate, recognize achievement, support training and develop good financial focus across the entire workforce. According to Hackett and Spurgeon (1996), managers should also adopt ‘culture’ of vision through the promotion of core values. It is crucial that to change the culture of an organization there needs to be considerable investment in an organizational wide employee development programs. Managers can also adopt forms of rewards and recognition through employee of the month awards, staff suggestion schemes, use of token gifts and forms of recognition with peer groups can also be done.

Viney (1997) sums leader up as such, one who is the embodiment, or perhaps the voice, of the company’s culture, must be a figure who will engage the sympathies or excite the respect of a broad cross-section. Inspirational leadership is required who can frequently contact with employees and can use varied forms of communication technologies which use formal and informal channel and also generates enthusiasm and powerful messages to wider workforce. Leader should also look at success and strengths within the organizations which are needed to boost morale and build optimism within the organization. In changing the culture of NHS, it is of utmost importance that the leader clearly and openly states indeed what changes need to be made, upon proper diagnosis. In an organization like the NHS, there appear to be problems not only with the service to the public, but more over with communication in the organization, leader must impose new practices that will aim to involve staff in everyday operations associated with changes being made. In an organization where uncertainty causes anxiety amongst individuals, openness would provide an environment where individuals feel a sense of assurance of their future. Employees that are happy and motivated deliver better service and are more open to change by upper level management.

5.2 Cultural Change

People are the must important part of the organization culture. But what is organizational culture? Robbins (2003) is relating the culture to the people as:

“A system shared mining held by members that distinguishes the organization from the other organization”. But, Schein definition is defining the culture better. Schein (1977) define the culture “the deep, basic assumptions and beliefs shared by organizational members”. Moreover Mullins (2002) defines that three factors or combination of them can develop the culture over time. These three factors are history of the organization, primary function of the organization and the goals or objectives of the organization.

Edgar Schein (1985) suggested the unique model for analyzing the organizational culture. In his model culture of the organization is divided into three main levels by considering the visibility and accessibility of people. His model of culture gives the leaders and managers powerful tool in front of the organizational culture and the process of understanding the existing culture and for implementing new cultures. In Schein’s cultural model culture is the design of basic assumptions by individuals and group of individuals which lie behind their values and beliefs. And the visible part is the behaviour patterns of them like individual behaviour within the firm, dress codes, colors, office shape...

Schein’s three levels of culture (Schein, E 1985)

 

As Huczynsky& Buchanan (1985) are describing at the most recent level (surface) culture manifested in company objects, architecture, rituals and language. Values are moral and societal principles that members achieve within the time and experience. Many researchers believe that values are the main point of the culture. But Schein himself emphasizing on basic assumptions as main and original part of the culture. Basic assumptions are organization’s culture in Schein Model. Huczynsky & Buchanan mentioning that they are “invisible, preconscious and taken for granted understandings held by individuals with respect to aspects of human behaviour, the nature of reality and the organization’s relationship to its environment”.

Types of organizational culture:

Each situation is unique, so each organization has different kind of culture. According to this situational view we identified different kinds of culture within the various kinds of organizations. Charles Handy (1993) identified four kinds of organizational culture:

• Club culture or Power culture: All issues and communications lead to the leader.
• Role culture: Job is more important than the individuals themselves. (bureaucracy)
• Task culture:  Based more on expert power than person. (Medical teams)
• Person culture or existential culture: Individual is in the center of concentration.

                                                                                                       (Source: CMI, 2003)

Organization culture and Change

Cultural control: Buchanan and Huczynsky (1985) are mentioning that employees respond to new culture in three ways:

1. Collude: submit the new culture and values entirely
2. Capitulate: faking the new culture and values
3. Resistance: resist the new culture

It brings the necessity of cultural control for managers in the process of change. This control can be direct or indirect. Indirect control will focus on sharing values and customer focus and learning issues. This Model of cultural control can be applied through Schein model of culture and be analyzed through that but by the feedback of control in each and every level of implementation.

Organizational culture and change

Senior (1977) describing that some element of culture can be supportive for change and some other can be defense against the change process.

Organizational Culture and Change

Source: Senior, 1977.

For implementing the cultural change we can use the normative systems model for cultural change. (Source: Allen, J 2006)

In this track we mentioned to two methods for cultural change which were Schein model and normative model for cultural change. Moreover we can mention to another model for cultural change which is Lundberg’s (1985) model of cultural change. Lundberg’s model is based on the notion of crisis and crucial view of leadership and continuing change through learning. As more or less this method is similar to normative system, we analyzed the cultural change through normative system supported by Schein model.

What about NHS?

 In the case of change in NHS as Lles & Sutherland are mentioning the culture can be important enabler or inhibitor of change. NHS is large organization with various kinds of people. It is complex organization with many different cultures and norms. Before the change program the culture of Top- down hierarchical organization with focusing on role and job was the common routine of the work. After implementing the change and clarifying the importance of cultural change, they widely used the supportive side of the organizational culture and managerial subcultures within the NHS. By introducing the new values and paths for the employees, change agents tried to shape the employees basic assumptions and paths (Schein Model). Now NHS is applying the combination of different organizational cultures by focusing on the Task culture and empowering employees and patients and much less hierarchical processes. As Lles & Sutherland describe that:

By supporting organizational culture, NHS is not a single culture but the collection of different subcultures such as managerial, clinical, task or professional and so on. Cultures which support change can be characterized by these factors:

First purposed design structures instead of hierarchical, second focus on skill instead of status and rank, Third open-risk approach, fourth opens to research and evaluation by empowering and finally focusing on teams and building self image and sense of achievement.

5.3 Motivation

Large amount of research exists in terms of change and management of that change. However there is a paucity of research on employees’ reaction to that change. Firms operate with an ever changing fast paced environment where they go through endless change and the ability to change is more of a competence of a business which is required for sustainability of the business (Paton and McCalman, 2000). But no change implementation can be successful without employees’ commitment and readiness to accept this change (Herscovitch and Meyer, 2002; Noble and Mokwa, 1999). However change is most commonly met with resistance (Caldwell et al., 2004). Managers take into account how change will affect performance but what they also need to consider is what affect the change will have on employees.

According to ‘The Dance of Change’ (Senge et al. 1999), people need to leave the comfort zone where they are very happy to stay and move to the discomfort zone. 

Comfort Zone

This is a zone where people are happy to stay. Things are familiar and certain. Work is more comfortable and scheduled. However in this zone people don’t learn anything and therefore do not change.

Panic Zone

This is the place where people are forced into when confronted with change that they do not agree with. In this zone, people are stressed, worried and fear change. Adequacy and frustration freezes people and they do not change.

Discomfort Zone

This is the zone where people feel a bit uncomfortable and will be willing to learn and change. What leaders need to do is motivate the staff to come into this discomfort zone. The staff needs to feel safe and that is possible by creating the right environment and culture. The employees need to see ‘what’s in it for me’?

Motivation and NHS

The Central Government in the UK had started a national reform for the public sector which resulted in new guidelines and initiatives for the NHS. Constant new reforms made it impossible for the last guidelines to be embedded in the system properly and new ones came (Ham, 1999).

“I think at the moment there [are] just so many changes, you’re just coming to grips with one, and then immediately being told something different. So it’s almost you just don’t get the time to come to grips with things, and settle things down, and then sort of a set of new policies, protocols, procedures. And then it’s all changed again."

(MORI, Agenda for Change, 2006)

As one can see from the quote above the employees were having a hard time accepting, digesting and implementing changes when the change was not stopping. The organizational structures were being constantly reviewed and re-structured and this caused a lot of confusion between people and their roles. All this contributed to a perceived lack of direction and focus.

“This reorganization thing – [we] are constantly being reorganized because I’ve been a head of department for four years and we’re on our sixth line manager. You move a step or two forward and then you’re reorganized.”

(MORI, Agenda for Change, 2006)

Another reason for low staff morale in the NHS was the fact a lot of financial problems were emerging due to the constant change plans. There were more things to do and not many people to do it. Staff shortages were prominent but nothing was being done due to lack of funds.

“I am sick to death of hearing that the NHS is over spent, when we’re not overspent. We’re under funded.”

(MORI, Agenda for Change, 2006)

Employees were sticking to the job in NHS due to the satisfaction they got from taking care of patients and generally helping people (Graham and Steele, 2001). NHS was known as being a place which doesn’t pay that well. However one more thing good about NHS was the terms and conditions of the job. For example, pension arrangement was one key benefit of working for NHS. Flexible working hours was another good benefit for working in NHS. Plus there was job security, an appropriate sick leave and training was provided for people to grow.

“There’s no other good viable option. I’m really just working for my pension.”

“I think within the NHS there are advantages, now, it has been a more or less secure job, up until now. You know that you’re getting your salary at the end of the month; you know your terms and conditions. So in that way there are worse employers.”

(MORI, Agenda for Change, 2006)

Steps Taken by NHS

Lots of research has been done about what NHS should do in terms of staff motivation in NHS. The steps taken by NHS were as follows:

• NHS used a two way communication method.
• A proper route was mapped to show the ‘current reality to the new vision’. What the Agenda of change was.
• Listening and acting on feedback, questions and concerns.
• Every small success or milestone met was communicated to people so that they could celebrate.
• Even bad news was communicated as mostly people just prefer to ‘know’, good or bad!
• Provide specific goals for people were given and training was given where necessary. Rewards… Pay and Holidays were to be  reviewed every year.
• They recognized that there was a difference in the rate of uptake of change. Identify Innovators as they lead change.

However in some area people still felt that the communication about the change was not proper and in some areas people were satisfied. What NHS needs to realize is how important it is to sustain and keep the staff motivated throughout the ten year change program. These steps are not a one off act and needs to be looked at again and again. The organizational pulse needs to be taken at different intervals to see how the employees feel and to check their self esteem.

Dos and Don’ts for NHS to keep in mind

Do

• Identify with people, what makes them tick and show genuine care.
• Lead, guide and encourage staff on a continuous basis so that they don’t feel lost or unappreciated.
• Top management needs to realize that they might not have all the answers all the time and it’s ok to be in that state.
• One thing that motivates employees in NHS is the satisfaction they get from helping people. Therefore highlight how the change plans will help the patients and public in the future.

Don’ts

• Force people into things you believe is ‘good for them’.
• Assume everyone is the same.
• Delegate work but also the responsibility.
• Ignore the need for continuous inspiration and support.

5.4 Empowerment

According to (Binney and Williams, 1997) empowerment can be seen as freedom within a framework, which provides clear boundaries within which people can experiment. (Herriot and Pemberton, 1995) have suggested two contrasting definitions, the first being, ‘Empowerment is passing the authority down the line’ and second ‘Empowerment means more responsibility same rewards’. It means different things to different people, making the term ambiguous and contested. Some view it as a means towards managerial ends while others perceive it as a desirable end in itself, (Edmonstone, 2000) which was the rationale behind the change that took place at NHS.

Empowering and involving frontline NHS staff, patients and providers was a key task in achieving their change objective. Employee empowerment was not only a tool that would lead to the facilitation of the change initiative but was amongst the objectives of the initiative altogether. To achieve this objective NHS implemented the Communication Strategy, the objective of which was to provide clear, timely simple information to employees, patients and providers, and making this information sharing a two way process. (Sargeant, 2005) This inevitably leads to a greater degree of trust eventually leading to collaboration through minimal resistance. According to (Goman, 2000) ‘ staff don't trust leadership, don't share the organization's vision, don't buy into the reason for change, and aren't included in the planning -- there will be no successful change -- regardless of how brilliant the strategy’.

We have used the Blanchard’s Compact model to describe the empowerment plan at NHS. The model describes how empowerment transcends through the three stages of communication, autonomy, and self management.

Creating autonomy is a crucial tool for empowerment as per the second level of Blanchard’s empowerment model.  Taking the example of NHS, while trying to empower employees and patients alike, it proposed a governance model based on a new notion of social ownership modeled on cooperative societies and mutual organizations, to be institutionalized by transferring control to the “local communities” served by foundation trusts. But this proposed governance model prompts serious doubts. The internal governance of trusts will have boards of governors, of which most will be elected by “the patient and public membership,” some from the “employee membership,” and the rest will be nominated by “partner organisations” such as local primary care trusts or universities. In turn, the board of governors will choose the chief executive and the non-executive members of the management board responsible for the day to day running of the trust. However the board of governors will be self selected. Anyone who is living in the neighborhood , who has been a patient, or is an employee will be eligible to register and vote. According to (Klein, 2003), it would have been visor to have given exclusive autonomy to the employees, rather than have a mixed cooperative of consumers and producers, as staff responsible for their own institution are much more likely to welcome strong management, instead of resenting it than if they see themselves managed by others. As per Blanchard the final stage to achieve empowerment is through reducing hierarchical thinking and replaces them with self managed teams. In trying to do so, NHS implemented a management de-layering strategy. However instead of empowering it has led to reduced motivation level as managers are facing increased work loads (Mullins, 2005) and   increased employee turnover, as they perceive themselves to be easily dispensable. (Middle-managers feel under the weather in the NHS, 2003)

Summarizing the above, if the promise of a devolved service with greater autonomy for those actually doing the work is to be achieved the model needs a great deal more development.

As many change gurus and researchers tell us, generally 75% of the change initiatives fail to meet their objectives (Bevan, 2003), as they try to boil the ocean rather than addressing each aspect individually. This may also have been the case with NHS, which plunged in for a large scale change initiative. Managers at NHS tackled many priorities simultaneously in different ways, not making the best use of their available resources, skills and knowledge. Applying the change program to the model of Sirkin et al. (2005), which specifies four denomination that determine the outcome of any transformational initiative, the following findings were propounded.

The first being in terms of duration. The general change attitude in NHS is that change needs to be implemented and achieved quickly. However the theorist say that it is not the duration of the change that matters, but having a programme with formal, senior management led, review process. A regularly reviewed longer project is more likely to succeed than a shorter but irregularly reviewed one.

The second dimension as per the model hat hinders successful change is performance integrity. Which means the right mix of people needs to be selected for the project, with the credibility and influence and effective change skills. As noticed in the change plans of NHS, innovators and policy makers form the ‘star teams’ to drive the implementation of the project. However we believe that involving a representative from every functional department and creating sub teams with representatives from every level of the hierarchical structure ensures that concerns, problems and suggestions of all are kept in mind while preparing a change plan.

The next factor being commitment. Commitment can be solicited through active and visible participation from the most senior leaders, and creating enthusiasm in the staff. This can be achieved only through communicating the reason for change to the staff, and getting them to believe that it is worthwhile, as they are the ones who will be operating with the changed systems and structures on a daily basis. NHS change initiative can be characterized by low commitment and communication from the senior leaders, leading to low levels of commitment of staff. The top management need to develop effective top down communication and change the hierarchical thinking, as the existing relationship between the senior leaders and the doctors is more like a a viceroy and a village farmer from India. (Bevan, 2003)

The final dimension effecting change is effort. Effort refers to the amount of work required from the staff over and above the work that they perform in their routines. According to (Sirikin et al,2005), if the increased work pressure is less than 10%, the project scores 1 point, which keeps increasing with the percentage of pressure. The lowest score instates a higher probability of the project succeeding. NHS has a tendency to launch major change, simultaneously, not keeping in mind that the regular busy operations also need to be carried out, creating extra responsibility for the staff. Also the de-layering strategy increased the operational work load. Managers at the NHS need to analyze the percentage of increased pressures on the staff to analyze the probability of success.

The question at this juncture is whether change in such a large organization can be implemented effectively and fast enough to keep the staff motivated and committed.

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