Interview: Professor David Buchanan
The Sustainability and Spread of Organisational Change
SM
This is a Cranfield School of Management podcast. I am Steve
Macaulay and I am interviewing Professor David Buchanan today
about his book, The Sustainability and Spread of Organisational
Change which he wrote with Diane Kettley and Louise Fitzgerald.
Now after the PowerPoint launch slides have been put away, after
the booklets that have been communicating a big change have been
put in the drawer, the real work begins and this is the subject of this
book. As I understand it, there are two areas here: one is
sustainability. Does change carry on after that initial launch? And
also spread. Does it grow from small beginnings or does it fizzle
out?
Now, David, have I got that right first?
DB
Yes you have. Those were the two key areas that the book
explores: sustainability or the improvement evaporation effect, as it
is sometimes called; and spread, or diffusion, or what is sometimes
known as the best practices puzzle. Why do good practices, new
working practices, not spread more quickly than one might expect?
SM
So you examined and got data for this from work you were doing
with a huge change programme in a huge organisation – the UK’s
National Health Service. Would you like to give us a bit of context
there?
DB
Sure. The National Plan, which the Government published in 2000
for the modernisation of the NHS, has been described as the single
largest organisation development programme carried out in any
sector, anywhere, ever. In England alone that affected 1.3 million
staff within the Health Service, and the NHS internationally is one of
the largest employing organisations on the planet, and it is only
organisations like the Indian Railways or the Chinese Army which
employ more people. Possibly the Egyptian Ministry of the Interior
– they reckon to employ about 1.4, but the NHS with 1.3 is a large
complex organisation.
So the NHS plan for modernisation and improvement was a major
strategic transformation. The single main thrust – let’s not go into
all the picky details, but the single main thrust of that was to develop
the service that was run in the interests of patient led service, rather
than in the interests of staff, and in particular professional medical
staff, which was the perception of the way it was being run at the
time.
Professor David Buchanan
SM
Now, I realise you have written a whole book on this, but broadly
what did you find?
DB
It might be useful if I give a very brief indication of what the NHS
found, which took us into the research that led to the book. The
NHS in order to facilitate this major Organisational Development
programme, major change programme, set up the modernisation
agency which was like an internal OD department which would act
as a catalyst, as a facilitator, as a support organisation, but also as
a driver for some of the main changes that were taking place –
some of the main initiatives and programmes.
What the modernisation agency staff found at quite an early stage,
was that some hospitals were making major improvements, major
gains in terms of for example, reducing waiting lists for operations
which is one of the main public concerns, and still is. Whilst
hospitals were making rapid major gains in cutting their waiting lists,
when they revisited some of these hospitals a year or two later,
some of them had maintained those gains, but in some the gains
had been lost. Why? In other words, the improvements had
evaporated and there were no obvious reasons that they could see
as to why that should happen. So that was one issue.
Another issue was that in some clinical services new working
practices were implemented, they were proven to work, they were
demonstrably effective, but the same service in the next hospital
down the M1 hadn’t implemented those changes, or even
sometimes on the same sites. Changes in one clinic that had been
very successful but the clinic next door, which sometimes even
share staff and share medical staff, they didn’t make these changes.
So why did best practice not spread faster, when it would be proven
effective? So that was the subtext to the study, in other words,
improvements were being achieved, but not sustained. Best
practices, new working practices, effective practices were being
developed and proven effective, but they weren’t spreading across
the system. So that was what we were finding as well.
SM
So that is quite disappointing in a way, particularly given all the
money and resources and so on which were ploughed into it. And I
guess that is true with many change initiatives.
DB
Well I think disappointing is a rather strong word and I would
challenge that from a couple of perspectives. One is that in any
change, especially major change, you are doing something for the
first time, new, innovative. Therefore by definition you don’t know
what is going to happen and also by definition you are going to
make mistakes. If you try windsurfing, you get on the windsurfer,
you get out on the lake or out on the sea you are going to fall off
because you have never done it before. So you expect things not
to work out the way that you have planned. I think that is a
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Professor David Buchanan
reasonable assumption.
And I think also I have perhaps just to describe the context,
overstated the case. This wasn’t happening in every hospital, in
every clinical service up and down the land, but it was happening in
enough settings to cause concern. Particularly because
government ministers were asking the question – if my hospital, in
my constituency can reduce waiting lists for operations, why can’t
they do it in Sunderland? And nobody had a good answer to that.
One has to accept that behind some of the problems, there was a
lot of success and behind the research questions, there were a
number of political questions being asked as well. So it made
sense for the service to be able to answer the politicians, but also to
be able to find a good answer if possible as how we apply those
things that were happening or not happening and how we could
improve it.
SM
From the book I noticed that you did come up with some answers,
but there were quite a lot of causes. If we look at what you have
described as the best practice puzzle, why didn’t it spread? What
were some of the major reasons? I know each time you have listed
about a dozen, or eighteen even in some cases, but what are the
main ones why the best practice puzzle was there?
DB
The problem with answering that simply and quickly is that it differs
from site to site, differs from case to case. In health care, one of
the main kinds of problems is resistance from medical staff and one
of the main reasons for resistance from medical staff is that the
targets that they are being urged to hit – the performance targets
they are being urged to achieve – don’t often in their view have any
clinical basis. In other words, they are political targets, they don’t
make any clinical sense.
One example that springs to mind is the waiting time for diagnosis
and treatment for cancer. And initially this was known as the two
week wait. So if you were a woman and you were diagnosed with
suspected breast cancer, there was an expectation that you would
wait no longer than two weeks before you saw a hospital consultant
and investigation treatment had begun. When that was
demonstrated to be achievable, the same target was applied
gradually to all cancers – including male prostate cancer by the way.
So there was a four week wait – once you had been diagnosed with
cancer there was supposed to be a four week wait before treatment
kicked in. That applied to all cancers, not just to breast cancer.
The problem with male prostate cancer is that one of the main
treatments is radical prostatectomy – they take it out. Another main
treatment is what is called watchful waiting because a lot of prostate
cancers are relatively benign, they don’t kill you, it tends to be an
elderly man’s disease and very often something else will kill you
long before the prostate cancer does. The problem of course then
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Professor David Buchanan
is that because all patients are expected to follow the same pathway
at the same time, male prostate cancer patients are being treated as
quickly as other cancer patients, leading to the possibility or two
possibilities – one is that if you treat patients who are perhaps not
as seriously ill as others to the timeframe, then those who are
seriously ill don’t get the additional attention and those who are less
ill get more attention. The other possibility is that patients are
pushed into more radical invasive treatments than would otherwise
be appropriate.
So where medical staff saw that the targets that they were being
forced to achieve didn’t have any clinical basis, they tended to reject
both the targets, and also some of the changes that were required in
order to achieve them. So I think that medical resistance is one
perception, but some of this was just a political whim.
Another set of reasons concerns the internal organisation politics.
If you, as a manager, or a doctor, do something radically different
and new and it is successful you get a gold star for being
successful. If you as a manager or doctor do something risky and
new and innovative and it doesn’t really quite work out, you often
get the gold star for being entrepreneurial and innovative and risk
taking. So that’s fine, so you have people doing that, implementing
these changes and getting the gold stars.
Now let’s talk about the spread issue. You are in the unit next door,
you are in the next clinical service, you are in the next hospital – if
you copy what I have just done, and you are a success, you won’t
necessarily get a gold star because all you have done is copy what
David has done. But if you copy what I have done and you mess it
up, you are in real trouble – you mean you can’t even copy what
someone else has already done? So in other words, you have got
an asymmetrical distribution of gold stars and black stars for the first
movers, the risk takers, the innovators and those who might copy
and come afterwards. So if there is nothing in it for me to copy you,
why should I? And that then becomes a barrier to the spread of
new working practices.
So that’s two – clinical resistance and just the internal politics.
There is, I think, a third one. And the third one is that some of the
new working practices which sound very simple and are very simple
targets in terms of explanation, require quite a complicated mix of
changes to put in place. And even achieving something like a two
week wait for cancer patients in one of the sites we looked at that
required not just a change to the diary system, it required changes
in medical and nursing and managerial roles. It involved
relationships – inter organisational relationships, the relationship
with primary care and GP referral protocols. It required changes in
physical facilities – they built a new day care centre – and of course
all that took time. So all we are talking about, changing the waiting
time for patients or introducing patient booking, the list of things that
actually have to change is actually quite long and complex and if
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Professor David Buchanan
you are now talking about new technology, new diagnostic
equipment, new physical facilities, day care, you are not going to do
that this afternoon. That could take a year or eighteen months, so
it’s another package of changes. So a two week wait, a simple
target, the changes that have to be put in place to accommodate
that can actually be quite complex and expensive.
SM
Yes, I think what you seem to be saying is you need to look very
specifically at what change we are talking about, to unpack it pretty
carefully and look at vested interests, the complexities involved and
so on which I guess goes back to the point, slightly disappointing
from a practitioner point of view, that says there are no universal
templates and tick boxes here.
DB
Ah, well, if I could mention one universal template that is in the
literature, in the practitioner literature, which is the model called
Copy Exact. In other words you take a working routine, whether it
is healthcare or insurance, whatever, you take a working routine,
you examine it in great detail and you basically bottle it and sell it.
In other words, if you have got that hospital on the South Coast you
work out exactly what it has done to cut its waiting times, you put it
in a car, you drag it up to Newcastle and you give it to them and you
expect them to cut their waiting times starting on Monday. The
Copy Exact method and that is quite well documented.
The problem of course is that the hospital up in the North East is in
many ways the same as the one on the South Coast because it is
part of the NHS, but it is totally different. It has got a different
history, it treats different kinds of patients, it has got a different
organisational culture, it’s different in size, the internal physical
layout is different, the age of its IT systems are all different, it has
got different legacy systems. And the technique, the system, the
approach, that you have just copied exact won’t fit. It has to be
tailored and while in some cases that tailoring might be relatively
straightforward, just a bit of fine tuning around the edges, in a lot of
the cases that we looked at the term adaptation, or tailoring, actually
involved more or less going back to first principles and starting
again with a general framework or a general outline, but the whole
concept of Copy Exact doesn’t work. It only works if you are
copying from one setting to an identical setting and in healthcare
that is not what you find.
SM
The other area that you explore in quite a bit of detail is where
everything seemed to be going fine and then the improvement
evaporates. Can you give me some feel for, and maybe some
examples of, where that happened and also importantly any clues
about what we should do about that?
DB
The main cause for concern, I think, at the time was with reductions
in waiting times. There has now been a lot of research
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Professor David Buchanan
subsequently done into that, but if hospitals were able to reduce
their waiting times, that was seen as desirable from the clinical point
of view. But also a lot of the research and media commentary
suggested that was something that the public were interested in –
you and I were interested in. And if you have had to have some
kind of elective procedure over the past ten years, the first thing you
do is check on how long it is going to take and then you might even
decide to go private – as I had to do on one occasion.
So cutting waiting times became a major public concern and that
was one of the concerns that we looked at. To put it very simply, I
think one is that any new set of working practices comes under
threat, potentially, from a broad spectrum of different factors. We
identified about a dozen, but it’s not just necessarily one thing that
can cause that set of practices to fold and decay, there are a
number. One of favourite ones of course is that the person who
implemented it, the champion, the person who got really excited
about it and took it on board to put this in place, they leave and the
way the NHS plan was funded involved the temporary appointment
of project managers – usually for a couple of years at a time, say –
and you and I will know, if you are appointed to a fairly senior
change post for two years, what are you doing once month eighteen
kicks in? I am afraid you have to start looking for other work and of
course, because some of these initiatives were seen to be that
person’s initiative, when they took their attention from it, when they
left, the initiative itself left. So one of the vulnerabilities is key
personnel; another of the vulnerabilities is just simply funding. In a
fairly rapidly changing area like healthcare, especially with new
government initiatives coming on board time and time again,
initiative decay, initiative fatigue – there is just so much change and
very often if a new initiative comes on – if the government says we
must be doing this – you are almost forced to stop paying attention
to last month’s set of issues and start paying attention to next
month’s set of issues.
So there are a number of different factors that will vary from site to
site, which cause initiatives, which causes changes to decay. One
of the single main sets of factors that I haven’t mentioned is the
observation that what you need to do to cut waiting lists in the first
place is usually quite different from what you need to do to keep
them cut. It’s like losing weight I’m afraid – if I want to lose weight,
which I do, there are lots of things I can do to achieve that before
my summer holiday, but I can’t keep doing that. If I want to keep
my weight down I have to make other longer term systemic
changes. And that was probably one of the main explanations,
alongside the loss of key staff, was that there wasn’t an adequate
recognition at the beginning that what we need to do to cut waiting
lists up front is to throw money and resource at the thing. That is
different to what you need to do to maintain those targets.
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Professor David Buchanan
SM
So if I draw the threads together and I said to you if there are some
key messages that you wanted to leave people with about
sustaining and spreading change going forward, what would you
say to them?
DB
Well if it’s about sustainability, the people issue is key. If you have
people who are supporting that initiative, who are behind it, who are
putting time and energy and effort into it, it is all too easy for them to
move on. So if you can find a way to either retain those individuals
and/or to ensure that when they are replaced you replace them with
a similar mindset or that they have the same goals. Very often
when we replace a chief executive, the incoming chief exec is given
a free hand. There is no reason in principle why an incoming chief
exec or head of department can be given a free hand, but one of
your targets would be to maintain that particular initiative or
programme and not let it die. So, I think personnel is key.
I think the second one, as I said earlier, is vigilance. Keeping those
issues on the agenda, because in other contexts I have seen major
change programmes just simply literally evaporate because another
major change programme came along. People have still got the
TQM mug and the TQM certificate on the wall, but the activity has
gone because we have moved on to some other initiative now. So I
think keeping items on the agenda and maintaining vigilance is key.
In terms of spread of best practice, I think the issues are different.
It is about ensuring that the key players in the organisation who
have the power to either run with or block those initiatives support
them. In healthcare that tends to be medical staff and senior
medical staff, but as a general rule if your senior medical staff
believe that that is a worthwhile valuable thing to do it will work. If
they don’t then they will probably stop it from happening or shut it
down after you have tried to put it in place. So I think that is key as
well.
Another issue with regard to spread and sustainability which affects
both of those issues, which I haven’t mentioned, is just the
importance of evidence, the importance of data. The NHS tends to
be data rich and information poor because they measure everything
every which way past Sunday, but it is important to have credible
evidence that that new working practice, that new system, that new
policy, that procedure, that patient pathway is demonstrably working
and is demonstrably effective and is demonstrably better. You
don’t have the evidence, and if you don’t have the evidence
continually coming through then that is often also another major
cause of evaporation, but it also inhibits others from picking that
practice up – show me the evidence, show me the numbers.
SM
Great. I think that has given some very useful pointers into what is
clearly a complex area, but a vital one. Thank you very much.
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