the story of change day

www.changeday.nhs.uk

By Kate B. Hilton & Chris Lawrence-Pietroni

Leaders Everywhere The story of NHS Change DayA learning report 2013

NHS Change Day is supported and coordinated by NHS Improving Quality.

NHS CHANGE DAYDo something better together

#NHSChangeDay

2 Leaders Everywhere The Story of NHS Change Day

PURPOSE, DESIGN & AUTHORS OF THE LEARNING REPORT The purpose of this report is to explore what can be learned from NHSChange Day 2013. Its intent is to summarize the lessons described bythose who took part in NHS Change Day; it is not a formal or independentevaluation. The report offers a narrative of what happened, explores theways in which people led and pledged their support of NHS Change Day,highlights lessons learned, and discusses the strengths and challenges ofthis approach. The report draws on interviews with core leaders, clinicaland non-clinical staff, the NHS Change Day website and a catalogue ofmaterials. It describes the immediate and ongoing impact of NHS ChangeDay through examples and stories that raise strategic questions for thoseinvolved in future Change Days and similar efforts.

Kate B. Hilton and Christopher Lawrence-Pietroni authored this report. In2010-11, Kate and Chris supported the QIPP workstream team onmobilising for cost and quality by developing distributed leadership skillsand adapting a community organizing framework to the NHS (resulting inCall to Action: Delivering QIPP and achieving common purpose throughshared values and commitment). Having been mentored for years by long-time organiser, Marshall Ganz, Kate and Chris consult with organisationsand voluntary multi-stakeholder groups to achieve shared purpose aroundhealth transformation. Their biographies are attached as appendices tothis report. Kate and Chris wish to express their gratitute for theopportunity to learn alongside those participating in NHS Change Day,and thank all those who kindly volunteered their time to share theirinsights, experiences and stories.

Front cover: Picture taken on NHS Change Day 2013 at Healthcare Innovation Expo.

CONTENTS

EXECUTIVE SUMMARY 4

INTRODUCTION & ORGANISATION OF THE LEARNING REPORT 7

CHAPTER 1: THE NATIONAL STORY 111.1 A Time of Enormous Challenge 11

1.2 The Birth of NHS Change Day 12

1.3 From Zero to 189,000 Pledges 14

1.4 Summary of Quantitative Research and Results 16

CHAPTER 2: THE PLEDGE MAKERS’ STORY 192.1 The Story of NHS Arden Commissioning Support 19

2.2.The Story of Open Minds Alliance CIC 22

2.3 The Story of Derbyshire Community Health Services Trust 24

2.4 The Story of Steve Fairman, NHS England 28

CHAPTER 3: LEARNING FROM NHS CHANGE DAY 2013 313.1 ‘Impact’ or ‘Design and Outcomes’? 31

3.2 Design: NHS Change Day, Social Movements and Hierarchy 33

3.3 Outcomes: Distributed Leadership 33

3.4 Outcomes: Relationships 36

3.5 Outcomes: Weak & Strong Ties 38

3.6 Outcomes: Voluntary Action 39

3.7 Outcomes: Mobilisation around Shared Values 40

3.8 Outcomes: Collective Action 41

3.9 Outcomes: Social Media 42

3.10 Outcomes: A Special Kind of Grasstops Leadership 44

3.11 Outcomes: A ‘Dual Operating System’ 47

CONCLUSION: LEADERS EVERYWHERE 49

RECOMMENDATIONS 51

REFERENCES 55

APPENDICES 57Appendix A: The Story of Barking, Havering and Redbridge University Hospitals NHS Trust 57

Appendix B: The Story of Birmingham Children’s Hospital 63

Appendix C: The Story of Jonathan Griffiths 66

Appendix D: Authors’ Biographies 70

3Leaders Everywhere The Story of NHS Change Day

EXECUTIVE SUMMARY

NHS Change Day 2013 was the biggest day of collective action forimprovement in the history of the NHS. A countrywide event in England,NHS Change Day was a grassroots initiative devised and driven by a smallgroup of emerging clinicians and improvement leaders. Their idea was tocreate a mass movement of National Health Service (NHS) staffdemonstrating the difference they can make by one simple act, provingthat large-scale improvement is possible.

The NHS Change Day core leadership team applied and adapted socialmovement theory, skills and practices associated with communityorganising and made use of social media to secure voluntary pledges fromNHS staff and patients to take a specific improvement or innovation actionon or around 13 March 2013. The Change Day team set themselves thegoal of securing 65,000 pledges, 1000 for each year of the NHS. Over189,000 pledges were secured on the online pledge-wall alone.

Change Day occurred in a context in which the NHS was under greatfinancial, organisational and reputational strain. This combination offactors created a climate in which NHS staff were under internal pressureand negative external scrutiny. NHS Change Day 2013 connected withthat moment, providing an opportunity to transform anger or frustrationinto constructive action.

This learning report was commissioned to tell the story and capture thelearning from NHS Change Day 2013. It draws on interviews with coreleaders, clinical and non-clinical staff, the NHS Change Day website and acatalogue of materials. It describes the immediate and ongoing impact ofNHS Change Day through examples and stories that raise strategicquestions for those involved in future Change Days and similar efforts.

Learning from NHS Change Day 2013The most significant learning from NHS Change Day is that change ofthis kind is possible; the most significant impact is that tens of thousandsof staff have now had the experience of taking part in collective action forchange.

NHS Change Day was an entirely voluntary effort that invited staff totake action on something that they were passionate about. It intentionallydrew on shared values, and in doing so, it unlocked willing commitmentto act rather than hierarchical compliance.

Putting shared values at the heart of the Change Day provided anauthentic ‘call to action’ to which others with a similar outlookresponded. It made Change Day not only an opportunity to do somethingthat would be of benefit to others, but also to express support for the NHSas an institution and the shared values that it represents.

NHS Change Day created a sense of urgency by focusing on a single dayof collective action. In many cases Change Day provided the necessaryprompt to galvanise and amplify activity that was already planned.Narrative skills were used to heighten and maintain this urgency and tosustain motivation.

NHS Change Day had a low threshold for participation encouragingpledge-makers to identify their own action rather than sign up to a singlenational initiative. This reinforced the model of distributed leadershipintentionally applied by the NHS Change Day team, designed to supportthe development of ‘leaders everywhere.’ The design of NHS ChangeDay was unique precisely because it drew together networks of


grassroots leaders while also enabling leaders with positional authorityto role model change leadership in a new way.

No permission was sought or given for NHS Change Day to take place; itarose from the initiative of those motivated to take part. In a traditionallyhierarchical environment like the NHS this modelled a profound shift inthinking and behaviour.

NHS Change Day was designed to be relational, which is one of thereasons it was so successful. Off-line teams made commitments to eachother supported by the online pledges made on the Change Day website.The social media presence supported the development of a communitythrough one-to-one communication via Twitter, shared YouTube videosand other interactions.

The relational nature of Change Day extended to many of the pledgesthemselves. A key insight arising from this experience is the importance offace-to-face human interaction not only in relation to patient care butalso feedback and communication between the NHS and the public andamongst NHS staff.

Because NHS Change Day was relational it developed new social capital.These new relationships have an intrinsic value for the people involved,offer a wider benefit for other NHS objectives, and provide newresources on which NHS Change Day 2014 can draw.

As with many social movements, young leaders played a particularlyimportant role in providing the energy that initiated NHS Change Day.However, NHS Change Day was simultaneously built on a foundation oflearning about social movements and the application and adaptation ofcommunity organising skills in a healthcare setting amongstimprovement leaders over many years.

In September 2013, NHS Change Day was a winner in the HarvardBusiness Review / McKinsey Leaders Everywhere Challenge.

ConclusionNHS Change Day offers an example of how new leadership can bedeveloped and deployed in healthcare. This model enables distributedleadership to flourish while not ignoring the realities of hierarchicalstructures and processes. There is often a tension between thecommitment-driven volunteerism of a collective day of action – which canbe unpredictable – and the temptation by senior leaders to requirecertainty, specified results or perceived success. In learning to embrace thistension, and to resist the pull towards more familiar behaviours andprocesses, the possibility emerges for a new kind of organisation that hasat its disposal both the standardising potential of hierarchy and therelational potential of networks.


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Summary RecommendationsEngaging with existing NHS processes: NHS Change Day 2014 shouldremain outside the formal NHS communication, improvement, training ormanagement structures.

Senior Leaders: Senior leaders should be encouraged to pledge as part ofNHS Change Day 2014 and should take the opportunity to model thevalue of enabling others to lead using their positional authority to hold upthe successes and stories of pledge-makers.

Structure: NHS Change Day 2014 should develop a more intentionalstructure of distributed leadership that allows teams throughout thecountry to take responsibility for particular aspects of the overall strategy(based on geography, professional groups, particular pledges, necessaryfunctions or some combination). Their roles should be clearly defined andthe core leadership team should in part be drawn from them.

Skills and capacity: Planning for NHS Change Day 2014 should make themost of new skills that have been developed by creating opportunities forthem to be passed on to others through trainings, webinars, online skillssharing, printed and online resources etc.

Emerging leaders: The growth strategy for NHS Change Day 2014should include a focus on identifying and recruiting young leaders from allparts of the NHS.

Patients and their families: The strategy for NHS Change Day 2014should consider what resources patients, their families and citizens ingeneral can contribute to the overall effort, as well as its leadership.

Integrate online and offline strategies: The strategy for NHS ChangeDay 2014 should include an online/offline element that draws inspirationfrom contemporary campaigns and social movements.

Build on successes: NHS Change Day 2014 should build on thesuccessful pledges in 2013, particularly those that mobilised largenumbers of people within a particular organisation or locality.

Campaign approach: An annual campaign to hit a target number ofpledges on a particular day each year is central to the Change Day design.While making room for new thinking, leadership and learning, a longer-term ten-year strategy for Change Day can help guide its growth withyear-round activity.

Goals and metrics: NHS Change Day 2014 should set an even moreambitious goal for the number of pledges secured. Additional metricsshould be considered including: impact measures directly from pledges,impact measures of effects of pledges on involved patients and staff, andmetrics around NHS Change Day design elements.

Opportunities for research: Change Day leadership, pledge-makers andresearchers should come together to pursue research partnerships,particularly around demonstrating impact from pledges and pledge-makers involved in Change Day.

Global movement: The NHS should invite others to join them in a world-wide “Change Day” with no one particular organisational affiliation, butthe same approach and objectives.


INTRODUCTION & ORGANISATION OF THE LEARNING REPORT

NHS Change Day 2013 was the biggest day of collective action forimprovement in the history of the NHS. A countrywide event in England,NHS Change Day was a grassroots initiative devised and driven by asmall group of improvement leaders and young and emergent traineeclinicians. Their idea was to create a mass movement of NHS staffdemonstrating the difference they can make by one simple act, provingthat large-scale improvement is possible. The effort was designed toengage the frontline in individual and team pledges to improve patientexperiences or clinical outcomes by spreading and adopting bestpractices and championing innovation. The aim was for 65,000 pledgesto be made, 65 being the number of years the NHS has been inexistence. Over 189,000 pledges were made.

This report explores some of the learning from this inspiring effort. It isorganized into three chapters: (1) narrative of Change Day; (2) learningfrom pledges, and (3) lessons from the approach. In Chapter One, weoffer a narrative of Change Day by describing the challenges facing theNHS at the time, the birth of Change Day as an idea, the leadership thattook it forward, their strategy to reach their goal, and a summary ofquantitative results. In Chapter Two, we offer the qualitative examples offour pledges to learn what Change Day meant to pledge-makers, andwhat pledge-makers meant to Change Day. In Chapter Three, weexplore our learning about this approach to change by examining itsdesign elements and considering the range of outcomes that flowedfrom them, the challenges and limitations that emerged, andopportunities for development in the future. We conclude this reportwith a brief summary of what we view as our greatest takeaways fromNHS Change Day and its implication for health care organisations theworld over.

HOW TO READ THIS REPORT NHS Change Day 2013 was the biggest day of collective action forimprovement in the history of the NHS. A countrywide event in England,NHS Change Day was a grassroots initiative devised and driven by asmall group of improvement leaders and young and emergent traineeclinicians. Their idea was to create a mass movement of NHS staffdemonstrating the difference they can make by one simple act, provingthat large-scale improvement is possible. In September 2013 NHSChange Day was a winner in the Harvard Business Review/McKinseyLeaders Everywhere Challenge.

The effort was designed to engage frontline staff in individual and teampledges to improve patient experiences or clinical outcomes by spreadingand adopting best practices and championing innovation. The aim wasfor 65,000 pledges, 65 being the number of years the NHS has been inexistence. In the event over 189,000 pledges were made.

Chapter 1: The National StoryStories are at the heart of all successful social movements; they are usedto call others to action, to sustain motivation in difficult times and tocelebrate what has been achieved. In Chapter 1, we tell the story of NHSChange Day from the perspective of the national leadership team thatbrought it into being. How and why did it happen? How did this teamcome together? How did they come up with the idea? How did theywork together? What challenges did they face? How did they overcomethem? What have they learned and what would they do differently? Ifthese questions are of interest, you’ll find answers in sections 1.1-1.3.

Quantitative results of NHS Change Day 2013 can be found in section 1.4.


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Chapter 2: The Pledge-Makers’ StoryStories are endlessly variable and can be retold in many ways. In Chapter2, we tell the story of NHS Change Day from the perspective of thepeople who made it happen on the ground – the pledge-makers. To dothis, we dive into four case studies, each of which illustrates a differentkind of pledge with diverse challenges, choices, outcomes and learning.

In section 2.1 the Story of NHS Arden Commissioning Supportexplores the unexpected benefits of participating in Change Day from agroup that did not initially connect with its approach, and thesurprisingly powerful impact of a pledge that engaged staff and citizensin face-to-face relationships.

In section 2.2 the Story of Open Minds Alliance Community InterestCompany reveals how a single pledge led to over 50,000 supporters,and how Change Day enabled an organisation outside the NHS to buildthousands of relationships inside the NHS, each of which has thepotential to improve the health and wellbeing of some of the mostvulnerable people in England.

In section 2.3 the Story of Derbyshire Community Health ServiceTrust illustrates how Change Day was used as a catalyst to amplify workthat is already underway, how the creativity of staff was unleashed (lookout for the Harlem Shuffle), and how supporting pledges at a local levelhelped to ensure sustainable impact.

In section 2.4 the Story of Steve Fairman, NHS England shows howaction by a single pledge-maker had unpredictable knock-on effect thatled to a chain of new insights and relationships, and the impact of apledge that at its simplest involved spending time in someone else’sshoes.

Three additional case studies can be found in Appendices A-C.

• In Appendix A the Story of Barking, Havering and RedbridgeUniversity Hospitals NHS Trust explores the pledges of threedifferent leaders and how they worked to enable others to exerciseleadership.

• In Appendix B the Story of Birmingham Children’s Hospitalillustrates the impact that a single enthusiastic individual can have bymotivating others, and how an institution like a hospital can replicatethe Change Day model locally, generating hundreds of pledges andsustained change.

• In Appendix C the Story of Jonathan Griffiths shows how socialmedia played a role in raising awareness of Change Day and buildinga national community of collective actors, as a GP spent the day in awheelchair in order to better understand one subset of patients.

We have drawn extensively on lessons and examples from the appendedcase studies in Chapter 3 of this report and included them in full as anadditional resource.


Chapter 3: Learning from NHS Change Day 2013This report aims to tell the story of NHS Change Day 2013 and to extractthe learning from that story. In Chapter 3 we draw the learning together.

Section 3.1 ‘Impact’ or ‘Design and Outcomes’? looks at the thornyissue of how to measure the success of NHS Change Day 2013. Whatwas its short, medium and long-term impact, and what are the bestmetrics for judging it? Is it possible to measure traditional improvementimpacts and how valuable would it be to measure new capacity foraction? What metrics should NHS Change Day 2014 adopt?

Section 3.2 Design: NHS Change Day, Social Movements andHierarchy considers what effect the application of social movementtheory had on the design of NHS Change Day, how this was adapted foruse in a vast hierarchical organisation, and what effect this had on thekinds of outcomes that NHS Change Day can enable.

Section 3.3 Outcomes: Distributed Leadership explores the model ofleadership used and developed by NHS Change Day, the extent to whichthis is valuable within the NHS and the challenges this poses.

Section 3.4 Outcomes: Relationships looks at the importance of off-line relationships in building and sustaining NHS Change Day, recruitingnew leadership to it and the legacy of these relationships in terms ofnew social capital.

Section 3.5 Outcomes: Weak & Strong Ties digs a little deeper intothe nature of the relationships formed through NHS Change Day, theparticular value these added to the effort and the value they could addto the NHS in future.

Section 3.6 Outcomes: Voluntary Action investigates a fundamentalprinciple that underpinned Change Day, what difference it made tooutcomes and the challenges of sustaining this within the NHS.

Section 3.7 Outcomes: Mobilisation around Shared Values looks atthe positive vision of NHS Change Day and how this was used as a wayof motivating others to take action through narrative and stories.

Section 3.8 Outcomes: Collective Action shares learning from pledge-makers and others about the experience of participating in a single dayof action and the effect that this had.

Section 3.9 Outcomes: Social Media draws together insights on theextraordinary role that a range of social media and online technologyplayed in enabling Change Day to happen, how the potential of socialmedia was actively exploited at all levels and what else might be done infuture.

Section 3.10 Outcomes: A Special Kind of Grasstops Leadershipfocuses on what NHS Change Day tells us about the role of seniorleaders in mobilisation efforts and the implications that this has for thekind of leadership that they may need to offer day-in day-out.

Section 3.11 Outcomes: A ‘Dual Operating System’ extends learningabout leadership into the kinds of formal and informal structures thatwere used by NHS Change Day and what this suggests about the valuefor the NHS of more intentionally operating through hierarchy andnetworks simultaneously.


Conclusion: Leaders EverywhereOur conclusion is not only that NHS Change Day was an extraordinaryevent which created significant new capacity but also that it helped tomodel the development of distributed leadership that makes the most ofthe standardising potential of hierarchy and the relational potential ofnetworks.

RecommendationsWe include twelve recommendations that draw on the learning fromNHS Change Day 2012. These are intended as a contribution to NHSChange Day 2014 and to assist others around the world interested inapplying a Change Day approach.


Stuart Sutton – GP, Becton Surgery, East LondonCore leadership team

Originator of the first tweet with Helen Bevan

CHAPTER 1: THE NATIONAL STORY

1.1 A Time of Enormous ChallengeChange Day occurred in a context in which the NHS was under greatfinancial, organisational and reputational strain. Although the governmenthad protected NHS funding, the service as a whole was looking to achieve£20bn in efficiency savings by 2015. At the same time, the 2011 Healthand Social Care Act had ushered in a period of restructuring intended toshift resources towards primary care by giving responsibility forcommissioning most services to Clinical Commissioning Groups led byGPs. Amidst these financial and structural challenges, NHS staff – likeother public service employees – were facing the consequences of thegovernment’s austerity programme in the form of an agreement to a two-year pay freeze in order to avoid compulsory redundancies.

Concern about patient safety and the standard of care provided theconstant background to this period of challenge for the NHS with regularmedia coverage of perceived failings and shortcomings. The long-runningseries of inquiries into major failings at Mid-Staffordshire NHS FoundationTrust exemplified this concern and published a series of damning reportswith wide-ranging recommendations.1 The inquiry was due to issue itsfinal report in February 2013 – one month before NHS Change Day.

This combination of factors created a climate in which NHS staff wereunder considerable internal pressure and frequently negative externalscrutiny. In the midst of this reality, many cynics dismissed the Change Dayeffort. Some felt that “committing” to a pledge was another way for linemanagers to get people to comply with improvement measures bydressing it up as applying ‘social movement theory.’ Others argued, “It isalready our job to improve the NHS; why should I treat this day differentlyfrom any other?” Still others worried that it was a politically charged effort

and wished to remain neutral. Some were too exhausted by their dayjobs, admitting that they didn’t want one more thing to have to do. Andothers felt that the effort would not produce measurable impact, citingpledges as “insignificant.” These cynics watched from the sidelines as anexplosion of energy and commitment from frontline staff created adifferent reality. Jackie Lynton from the NHS Change Day core leadershipteam stated: “At the end of it, onlookers shook their heads and asked‘How on earth did this happen?’”

It was as though NHS Change Day 2013 connected with a certain moodamongst those facing financial pressures, reorganisation and the imminentpublication of the final Francis Report into the failings at Mid-StaffordshireNHS Foundation Trust. The timing suggests the importance of the ‘sense ofurgency’ that surrounded NHS Change Day, as it provided an opportunity totransform people’s anger or frustration into constructive action.

The British people undoubtedly have a special relationship with the NHS.In a recent national survey, people said they cherish the NHS more thanthe Royal Family or thearmed forces (Katwala,2013). Politician NigelLawson famouslydescribed the NHS as“the closest thing theEnglish have to anational religion”(Katwala, 2011).” It isdifficult to imagine anyother country that


1 The inquiry was led by Robert Francis QC, and the reports are referred to as ‘the Francis report.’

NHS featured in the Olympics 2012

would, without irony, celebrate its health service in front of the world atthe Opening Ceremony of the Olympic Games. NHS Change Dayharnessed its people’s pride and passion for a system designed to takecare of its own.

The NHS is also the biggest health system in the world, serving the needsof a population of 54 million people.2 The sixth biggest employer in theworld, only the U.S. Department of Defense, the People’s Liberation Armyof China, Walmart, and McDonald’s have more people (Alexander, 2012).Everyday a million patients use the services of the NHS. It is a massivecomplex system – and as such, not easy to change. Yet NHS Change Daymarked the single biggest improvement event in any organisation in theworld. Why? Each and every one of its workforce of 1.7 million employeeswere treated as potential leaders of change.

1.2 The Birth of NHS Change DayThe story begins in 2012 when a conversation began on Twitter betweena GP and healthcare improvement thought leader. GP Stuart Sutton hadjust attended Helen Bevan’s talk on “Building Contagious Commitment toChange” as part of the learning programme run for Darzi Fellows by theKing’s Fund. Helen had worked for years to apply social movementprinciples to improving health care, in part as a response to some existingchange initiatives using Lean, Six Sigma and other industry approaches.Trained in community organizing methods, Helen encouraged others inthe NHS to learn from leaders of great social movements, people who hadfew resources, no hierarchical and positional power, but who deliveredresults by building power through collective action.

During her presentation, Helen asked the audience to describe the projectsthat they were working on. 70 percent described cost-benefit efficiencyprojects; and 30 percent described projects focused on quality, patientcare or the safety-experience. Helen then challenged her audience toconsider how the design of projects generates commitment from others.Was anyone up for doing something differently?

Helen’s provocation got Stuart thinking, and after the training he andHelen exchanged Tweets. They agreed to meet and talk more about what“mobilising young clinicians” across the NHS might look like. Paediatrictrainee, Damian Roland, joined the conversation; and Helen encouragedStuart and Damian to take seriously their passion to make a difference forpatients. Even though emerging clinicians like Stuart and Damian might beperceived as powerless and at the bottom of the NHS hierarchy, Helenunderstood that young people historically drive change, and that effectiveleadership comes from within a constituency, not outside it. In fact, in1948, it was the new generation of doctors who lived through the warthat were instrumental in overthrowing the established order and securingthe establishment of the NHS in the first place.

Stuart and Damian recruited other emerging clinical leaders to exploreideas over the course of two conference calls. The make-up of this groupreflected the engagement of Generation Y, who in previous years hadbeen focused on completing their clinical training and kick-starting theircareers. This growing cadre of younger leaders were active on socialmedia, ready to engage in change, and passionate about making adifference for patients.


1 The inquiry was led by Robert Francis QC, and the reports are referred to as ‘the Francis report.’

They ultimately took their inspiration for Change Day from Earth Hour, aworldwide event organized by the World Wide Fund for Nature (WWF),that encourages households and businesses to turn off their non-essentiallights for more than one hour to raise awareness about the need foraction on climate change. The first event took place at the end of March2007, when 2.2 million residents of Sydney participated by turning off allnon-essential lights. Following Sydney’s lead, many other cities around theworld adopted the event. By 2012, it was taking place in more than 7000cities and towns across 152 countries and territories.

The emerging clinical leaders’ initial questions were about what the NHScould do that was equivalent to turning the lights off. They askedthemselves, “What should we use as our goal? Should we identify aspecific action that we want everyone to take, or should we leave it topeople to take action that is meaningful to them? How will we measureoutcomes? Who owns Change Day, and how do we allow it to be led –and remain led – by the grassroots?”

The main difference between Earth Hour and NHS Change Day is thatEarth Hour is an umbrella movement that brings many organisations andactivists together in a common cause. NHS Change Day is a movementlargely inside – and alongside – a hierarchical system.

Jackie Lynton played a special leadership role in bringing this about. AsLead Associate for Thought Leadership & Change Model at the then-NHSInstitute for Innovation and Improvement, Jackie sat in on an earlyconference call among the emerging clinical leaders. She immediatelyrecognized their idea as a mobilisation project and saw its potential.Jackie established a strong coaching relationship with Damian, whoinitially wanted to give people a menu of two to three national pledges to choose from, in part motivated by a desire to measure impact.

Based on her own experience as a former clinician, Jackie encouraged himto consider the power of “not telling people what to do” but of givingthem the opportunity to decide for themselves. With her coaching, theemerging clinical leaders together decided it was critical to maintain abalance between igniting frontline engagement and using the leverage ofthe hierarchy to make positive change happen as a voluntary grassrootseffort. They wanted to create “leaders everywhere.”

Out of their initial leadership grew a core leadership team that recruitedother members with particular technical and organisational expertise. Therole of the core leadership team was to organise and mobilise people andput in place a range of channels, activities and platforms – particularlythrough relationships and social media – to enable individuals amongst theNHS and its supporters to join the effort.

Members of the core team included: Damian Roland (Paediatric SeniorRegistrar), Stuart Sutton (GP), Pollyanna Jones (NHS GraduateManagement Trainee), Kat Trimble (PR and Communications), JacquiFowler (Social Media and Knowledge Management), Joe McCrea (SocialMedia Strategy), and a team of improvement leaders from the NHSInstitute including Helen Bevan, Rachel Douglas-Clark, Michaela Firth,Stuart Hill, Jackie Lynton, and Alan Nobbs.

The ongoing coaching dynamic between the emerging clinical leaders andimprovement leaders played an important role. The improvement leadersprovoked the clinicians to take action, serve as role models, and act asspokespersons. Meanwhile the improvement leaders helped the cliniciansdevelop leadership skills and a campaign structure. In turn, the cliniciansprovided leadership ‘from within’ the frontlines of the NHS. They providedthe effort with real credibility among the clinical community.


Over the course of the next few months, the core leadership team workedtogether in the following way: they had one half-day strategy session to agreeto the goal, shared purpose and campaign plan; a weekly 1-hour WebExmeeting to agree to ongoing tactics and actions; hours of spontaneouscoaching and support across the team; calls to action to keep their energy upand motivate each other; and support from an oversight group made up ofsenior leaders. Here is what they did with that.

1.3 From Zero to 189,000 PledgesThe first challenge the team faced was to decide on a commitment-basedgoal. In other words, they could not create “leaders everywhere” throughcompliance; NHS Change day had to be underpinned by intrinsicmotivation around shared values, one that anyone could commit to.Initially they thought of asking everyone to take part to develop animprovement project inspired by some of the best practices approachesthat already existed. Some thought a target of 500 projects might beaspirational but reasonable. Others thought they could be more ambitious.At a strategy meeting, the goal of achieving 65,000 online pledges wasagreed – 1,000 for every year of the NHS. This was a nerve-wrackingchoice. How would they secure that level of commitment? Afterbrainstorming various ways in which this could be brought about, theydeveloped the concept of a single day of action. They had six months toget there.

This is the campaign chart that sets out the leadership team’s timeline forNHS Change Day and the “mountain top goal” of 65,000 pledges.

The next challenge point came in December. According to Alan Nobbs, theteam was working furiously to answer strategic questions like “How dowe get the message out? How do we filter it down? How do we helppeople focus on pledges that are important? How do we structureleadership, and how do we practice leadership? How do we enableothers?” Stuart Hill adds, “We were also facing our own challenges anduncertainty. With the restructuring of the NHS, many of us facedredundancy and redeployment. I personally felt challenged in givingChange Day the energy it needed in the midst of all that noise.”


Damian Roland agrees. “We did struggle in December. We were hugelybehind schedule, we were revisiting the strategic direction, andchallenging personality dynamics began to emerge within the team.Jackie Lynton, in particular, exercised leadership by renewing ourrelationships, shared purpose, and values to forge a new level of trust.”Jackie Lynton looked at her role as an improvement leader in a particularway. “I saw my role as fending off internal and external resistance toenable our young leaders to unleash their energy. It was about enablingthem – and all the members of our team – to do what they were good at.It personified the whole effort. I was saying I am here to support you, I amhere to enable you, I will deal with the rubbish. That is what our pledge-makers did too. Their pledges say the same thing to our patients.”

The New Year was a New Year. January marked the public launch of NHSChange Day, and that in and of itself energized the team. Along with itwas the public release of the NHS Change Day video and website. Theteam saw its own “story of us” personified in the urgent call to actionbrought alive on camera and online. Stuart Sutton pointed out, “Thepublic launch was a breakthrough moment. We got our narrative right,we made the connection to people on the frontlines real, and the film wasa brilliant recruitment tool. When I showed it to people, they got it!”

After the launch of Change Day, the number of pledges started slowlyrising. Although the core team had built a lot of relationships and askedmany organisations and individuals to make pledges before or on the dayitself, nothing could have prepared them for what happened. In the finalmonth before 13 March, Change Day took off.

The Francis Report was released on 6 February. It provided an urgentchallenge to call people to action. Feedback and requests for supportbegan to pour in from organisations and individuals. Social mediachannels began to build traction and traffic. On 14 February, the total was5,000. By 21 February it had grown to 43,000, and by t March it stood at80,169 – breaking the target with two weeks still to go. The 100,000-pledge mark was broken at lunchtime on Monday 11 March.By the morning of Change Day itself, there were 130,000 pledgesregistered on the website – double the target.

Liz Saunders from the healthcare policy think tank, the King’s Fund,blogged and tweeted on the evening before NHS Change Day: “If everyou’re losing faith that there is the energy to make a difference in theNHS… there are more than 130,000 pledges on there, people activelychoosing to make a difference to the services they provide and to patientcare. It’s uplifting.”

Change Day pledges poured into the online site throughout the day. The focus of NHS Change Day was England, but people caught the spiritin Ireland and made over 13,000 pledges from there. By the end ofChange Day, 182,000 pledges had been received. Over 50,000 had comein on the day itself. A further 1,000 were added the day afterward, and afurther 7,000 before the end of March – hitting a total of 189,000pledges listed on the Pledge Wall. That does not account for those whodid not list their pledge, which is estimated at over 300,000.


The success of Change Day led well-known NHS commentator, Roy Lilley,to declare: “Sometimes an event comes along that simply andfundamentally changes things. They call it a ‘gamechanger.’ The dictionarydefinition is ‘a newly introduced element or factor that changes anexisting situation or activity in a significant way.’ Well, I think we have anew Gamechanger. It’s called NHS Change Day. It happened this week,and it came from the NHS grassroots.”

1.4 Summary of Quantitative Research & ResultsWhat did the effort result in? What can be gleaned from the patternswithin the pledges? • The most profound finding was that ‘it can be done.’ NHS staff can bemobilised to take action around shared values. Over 189,000 pledgeswere submitted to the NHS Change Day website, and this total was afraction of the pledges made and carried out that day. As Joe McCrea,the Social Lead of the core leadership team, quipped, “This thing couldhave been a heroic failure in which case lots of the people who are nowsaying that they were always supporters would have been pillorying thecore team!”

• Since March, a quantitative analysis of the pledges was conducted.Survey research shows that the primary motivation for people to getinvolved in Change Day was to improve patient care, closely followedby “I wanted to make a difference,” and “I wanted to learn fromothers.” In contrast, the two least motivating factors to get involved inChange Day were “because I was told to” and “because I was askedto.” This finding demonstrates that intrinsic motivation around sharevalues was critical to Change Day’s success, not strategies based oncompulsion, compliance or exhortation.

• 54 percent of pledges on the website involved action taken by a singleindividual; 71 percent involved fewer than nine people; and 94 percentinvolved fewer than 50 people.


• Overall, 25 percent of NHS organisations took part. NHS Trusts led theway, in addition to wide support received from NHS-alignedorganisations and individuals. There is still room for improvement forengagement at CCGs and GP practices in particular, as only 5 percentof CCGs and 0.1 percent of GP practices were engaged (see left).

• 68 percent of pledges focused on better patient care or spreadinginnovation. 10 percent targeted personal development; 10 percent onusing services effective; 7 percent on celebrating services; and 5 percenton implementing integration (see left).

• 36 pledges encompassed almost 3,500 people involved in simply‘smiling’ with fellow patients or staff (see below).


Other metrics and patterns have been summarized in “The Difference aDay Makes – Interim Report from NHS Change Day,” published in May2013, “Biggest Ever Day of Collective Action to Improve Healthcare thatStarted with a Tweet” posted to the Management Innovation website in June 2013, and “What Did NHS Change Day Pledges Tell UsAbout What Matters to Staff and Patients?” submitted in June 2013.These publications also include metrics around the use of social media, atopic that is discussed in Chapter 3 of this report.

But what can we learn from pledge-makers themselves? This is where thespirit and soul of NHS Change Day was made real, where the action madea difference to patients and practices. The above-mentioned NHS ChangeDay publications describe many excellent and inspiring examples ofpledges received. This report does not. Instead, it looks carefully at fourdifferent pledges and draws out the qualitative learning from pledge-makers.


Victoria Stead, Receptionist,Becton Surgery, East London

http://www.changemodel.nhs.uk/dl/cv_content/64646

http://www.changemodel.nhs.uk/dl/cv_content/64646

CHAPTER 2: THE PLEDGE-MAKERS’ STORY

One version of the NHS Change Day story is what happened to initiate itand enable it to grow. This is the story that we told in Chapter 1. Anotherversion of the story is about pledge-makers on the ground and how theiractions made Change Day real to NHS staff and patients. In this chapterwe look at four distinct pledges in detail to understand their stories anddraw out the lessons they can teach us. These pledges come from (1) NHSArden Commissioning Support, (2) Open Minds Alliance CommunityInterest Company, (3) Derbyshire Community Health Services Trust, and (4)Steve Fairman of NHS England. (Three additional pledge-makers’ storiesare included in Appendices A-C; and we draw on some of their learningin Chapter 3.)

Before exploring these examples, it is important to note that the “behind-the-scenes” work of the leadership team was invisible to almost all pledge-makers. Most were exposed to the website, a video, possibly an email or aTweet. Colleagues encouraged them by word-of-mouth to make a pledge. It appeared as an opportunity to many people to take an idea and make itreal, to link existing local work to national purpose, or to step outside of habitand try something new – without asking anyone for permission.

2.1 The Story of NHS Arden Commissioning Support The pledge:Working with three local Clinical Commissioning Groups(CCGs) (NHS Coventry and Rugby CCG, NHS South Warwickshire CCG,and NHS Warwickshire North CCG), a team of over 50 NHSCommissioning Support Staff, lay people and patients formed a volunteer-based NHS Change Day team. They went into shopping centres,supermarkets, hospitals, GP surgeries and on the streets to ask people’sopinions about the NHS. The event took place from 9am to 7pm on 13March at 17 different locations across Warwickshire and Coventry.

Anna Burns, the Director of Strategy & Engagement at the NHS SouthWarwickshire CCG, explained: “Volunteers employed a four-stepdiscussion with individual members of the public that drew on theimportance of patient-feedback as outlined in the Francis Report. First, wetold them, ‘Today is NHS Change Day. If you could make a change to yourlocal NHS, what would it be?’ Then we asked, ‘How well do you feel theNHS listens to you?’ Next we used it as an opportunity to explain therestructuring of CCGs and how it would affect them. Last we recruitedvolunteers to serve as Health Champions. Everyone had a clipboard anddiscussion form for responses. We spent about twenty minutes with eachperson, and spoke with a total of 450 people.”

A logistics team coordinated with contacts at each local site, securedpublic liability insurance, staffed each site with volunteer coordinators, andprovided the requisite materials to each volunteer. Although volunteersapproached members of the public individually, they were assigned tosubgroups of two or three in order to support one another. The leadershipteam recruited volunteers via email and personal asks and thankedeveryone afterwards.

Why this pledge: Rebecca Davidson, the Communications andEngagement Lead, explained their reasoning. “In response to the FrancisReport, we translated our pledge as going into the community to askwhat changes the public would like to see and how well the NHS listens tothem and their concerns. Change Day was also happening during a hugetime of change with the establishment of CCGs. It was a timely reminderto the public about the restructuring going on and how it affected them.And it was really important that we have a vibrant engagementprogramme, so we used the opportunity to recruit Health Champions.Those were the main drivers for us.”


How they got involved: Anna Burns explained: “Jackie Lynton (from thenational NHS Change Day Team) asked us to consider getting involved. To be honest, NHS Change Day did not connect with us as an organisationin terms of making individual pledges. We are in a market town in a semi-rural area among a predominantly middle-aged white male group of GPsthat are engaged in improvement, but not in this fashion. In addition,March is one of the worst months for us because of the timing of thecommissioning process and the financial year starting on 1 April. If ithadn’t been for Jackie reaching out, I’m not sure we would have done it.”

Outcomes: The NHS Change Day team communicated to the CCGGoverning Body that they should devise more opportunities for people tooffer feedback to the NHS on the services they have received. As AnnaBurns captured in her formal report on NHS Change Day to the CCGGoverning Body: “Face-to-face meetings are an important method ofcommunication for people to raise concerns, and it is important that thefeedback is recorded and acted upon. Work also needs to be done so thatpeople know how to provide feedback, and to demonstrate that providingfeedback makes a direct difference to improving services… It is essential forthe CCG to engage with the public and patients to ensure that their viewsare fed into decision making and to ensure transparency.”

In addition, the CCG’s pledge allowed them to identify and recruit over100 local Health Champions. Health Champions are invited to participatein the CCG by (1) receiving regular news and updates about what ishappening in South Warwickshire’s health care services; (2) taking part insurveys and consultations to influence the development of services andhow the CCG spends its money; (3) attending events, health seminars andother patient and public involvement activities; and (4) engaging otherlocal people, patients and carers across the area. One in four people

surveyed on NHS Change Day agreed to participate in this programme,which accounts for one in ten of the presently enrolled Health Championsin the area.

Lessons: In the context of the pledge itself, the local team received directfeedback about how to improve confidence in the NHS: reducing waitingtimes; weekend opening hours for GP practices (and/or access to get anappointment should be improved); better communication, including moreinformation available in different languages; a helpdesk available for whenservice goes wrong; less political involvement; better staff training;improvements in care; and doctors focusing more on care and less on finances.

As for feedback to the NHS, 34 percent of respondents previously offeredfeedback about NHS services. Of those that provided feedback, most did soface-to-face, with letter being the second most popular method offeedback, email the third most popular, and phone the fourth. The majorityof respondents preferred not to be anonymous in their feedback.

There were a variety of reasons for not offering feedback, including: notknowing how to provide it; thinking it would be a ‘waste of time’ and notused or applied; being happy with the services and therefore no perceivedneed; or feeling decisions were already made. This taught the CCG thatthey should do more to let people know how to provide feedback anddemonstrate it makes a direct difference to improving services.

From a NHS Change Day perspective, the team felt the ‘urgency of themoment.’ Between the Francis Report and upcoming changes to CCGs,there were many reasons to engage the public more broadly. The team willuse this learning to develop future pledges in the real and present context“of the ‘moment’” when future Change Days occur.


Team members also valued forming relationships with the public face-to-face, which also proved an effective strategy for recruiting a large numberof Health Champions. Making personal connections allowed them tomotivate members of the public to join the Health Championsprogramme. In turn, volunteers valued the opportunity to take on apublic-facing role. Team leaders also built relationships with contacts fromrespective venues, and the CCG is likely to go back – or has already beenback – to those places for further outreach.

In addition, NHS Change Day provided an opportunity for senior leaders inthe CCG (15 people) to work directly with GPs and registered nurses (22people), as well as lay people and members of the public. As Directors,Anna Burns and Rebecca Davidson reported the benefit of spending timeas a larger team and working toward a shared purpose. This kind ofactivity allowed them to build stronger relationships across hierarchicaland organisational boundaries. Team members are now able to share ideasmore readily and make better decisions together because they can call onshared experiences with one another that demonstrate their willingness toimprove to the NHS.

Changes in thinking and leading: Anna Burns reported, “Becausepeople are not inclined to give feedback, when they do, the ability to offerthat feedback face-to-face is a really important mechanism. That was ourbiggest take-home message. We use social media and websites foroutreach, but what is important is to talk to patients and the public face-to-face. We need to make ourselves more accessible and talk to people.That really took me by surprise. To get feedback, we have to be visible, wehave to ask for it. It helps us to see how others see us; and it helps themto feel heard by us. Putting a response form on a website is insufficient.People want to talk.”

The team has subsequently run campaigns and involved volunteers indirect outreach with the public. They also use press releases, Twitter,websites and other social media to build capacity around programmes likeHealth Champions. They feel it is good to communicate more often andmore effectively with the public, especially face-to-face, and to invite thepublic to offer direct impact on the kind of care the CCG provides.

NHS Change Day approach: As Anna Burns reported, “Although we feltconnected to the national effort, for us, this was a very local pledge. We tweeted a photo of our team at the market in Coventry to the widerNHS Change Day effort, but really this was about Change Day inWarwickshire and Coventry. Our people knew less about the nationaleffort than they did about our local action.

“Our particular CCG has 15 staff. We are always asking them to improvethings, that is our job. Change Day feels a little bit like a false concept,because we should be continuously improving and finding solutions everyday to benefit patients. As a team we role model this behaviour, we donot accept mediocrity, we expect things to be better. NHS Change Day is auseful reminder to all of us that we cannot become complacent in whatwe are doing. Organisations who feel competent fail. If we are remindedto improve – at improvement – we will continue to try harder.

“I invited the GPs to join NHS Change Day and asked whether theywanted to do something in their own practices; no one wanted to do it.Some people feel differently [about this approach], and we have to acceptthose differences. Not that they don’t get engaged – they do in their ownway! But we can’t make people ‘do’ things. We have to meet peoplewhere they are. They saw what we did. Next year they may feel that it isrelevant to them. But it is not our job to impose it, just to encourage andsupport.” That is the spirit of Change Day.


“We positioned our pledge to coincide with Change Day, but we wereplanning to do it anyway. We framed it that way among our CCGs and GPpractices, so they knew that it was important to us, whether or not it wasa part of Change Day. It was important to keep the pledge simple, to alignit with what we were already doing. It had to be low-key, with a low-threshold to be involved. We didn’t spend extra money on it, we askedpeople for 3-hours of their time. We used resources we already had.

“We might look at Change Day through a different lens. The fact thatpeople said that it was so motivating to feel empowered to take action onone day, that signals that the rest of the time they don’t. That is a muchbigger problem for the NHS. NHS Change Day should be every day!”

2.2 The Story of Open Minds Alliance Community InterestCompanyThe pledge: “I pledge to share we can all get through distress and suicidalthoughts. There is always help/hope via U Can Copewww.connectingwithpeople.org.” This pledge was posted on 8 March, oneweek before NHS Change Day, with thousands of actions taking place overthe following weeks. The pledge was supported by a team led by Alys ColeKing, a Consultant Liaison Psychiatrist, together with the Open Minds AllianceCommunity Interest Company, based in London and North Wales.

Open Minds Alliance CIC was established in 2010 and provides suicideprevention training and resources aimed not just at medical professionalsbut society as a whole. As Alys Cole-King and Gavin Peake-Jones explain,“our belief is that emotional distress, and tragically, suicide still affects andtakes far too many lives. We felt that responsibility for people with suicidalthoughts was seen to lie with specialist mental health services and otherswere more nervous to get involved. However we knew that early

intervention from a colleague, friend, compassionate health provider orcare giver could make a real difference to saving lives.”

From the outset the objective for Open Minds Alliance CIC was to secureas many supporters of the pledge as possible. The pledge was deliberatelycrafted so that it would appear in a single tweet – the aim being to secureas many re-tweets as possible.

In order to support the pledge, each individual or organisation had tocommit to take some specific action that would spread the message of theU Can Cope campaign and direct individuals to resources that could helpthem if they were troubled by suicidal thoughts. “We had to be sure thatit was not just a paper exercise,” explains Alys Cole-King. In practice thismeant that every supporting organisation had to communicate the U CanCope message to their members, supporters or staff.

Why this pledge: For Open Minds Alliance CIC, participating in NHS ChangeDay was about much more than a publicity or marketing drive. Theirapproach to suicide prevention is built on a belief that it is possible to developthe protective factors of each individual and help them to gain knowledgeand control over suicidal thoughts and impulses. Alys Cole-King describes thisas, “a compassionate alternative to the so-called ‘management’ of suiciderisk…it promotes a role for all, and recognizes that each encounter with anindividual with suicidal thoughts is an opportunity to intervene and potentiallysave a life.” When she talks about promoting a role for all, she really doesmean all: the resources made available by Open Minds Alliance CIC areintended to be used by everyone and anyone.

How Open Minds Alliance CIC got involved: Alys Cole-King has beenworking collaboratively for many years on the issue of suicide prevention


and has a wide range of national contacts. One of these contacts, KathEvans, is Head of Patient Experience for NHS England and has workedclosely with a number of the NHS Change Day Core Team. When Kathheard about NHS Change Day she immediately thought of Alys and thework of the Open Minds Alliance. Kath knew Alys and her colleagueswere looking for a way to effectively engage the wider NHS and might beattracted by the possibilities offered by Change Day. So she got on thephone and invited Alys to make a pledge.

Outcomes: The U Can Cope pledge secured over 58,000 supporters –more than any other single NHS Change Day pledge. As the Open MindsAlliance CIC team point out this is an especially remarkable achievementgiven the social stigma associated with suicide. “Change Day had anamplifying effect,” explains Gavin Peake-Jones. “It enabled us to get to amuch wider range of people. It has been a catalyst to broaden thinkingabout suicide and has enabled us to have impact at all the different touchpoints. By breaking down stigma, people will get the support andresources that they need.”

Open Minds Alliance CIC was notably successful in securing the support ofa number of large organisations both inside and outside the NHS. These included The Royal College of Psychiatrists, The ProfessionalCricketer’s Association and The Rugby Player’s Association – all of whomcommitted to take action. In the case of the Betsi Cadwaladr HealthBoard, where Cole-King is Consultant Liaison Psychiatrist, this includedhanding out leaflets to staff and patients, two direct emails to all staff andcoverage in internal newsletters. “It was absolutely unprecedented,”reflects Cole-King. Other supporters included the College of EmergencyMedicine, which communicated the U Can Cope message to all itsmembers via its newsletter and Twitter and Barnsley Metropolitan BoroughCouncil which put a mailshot through every home in their locality.

From their own research, Open Minds Alliance CIC knew that people whoare in distress tend to be seen first in primary care and that there is adeficit of training and resources in that area. As a result of contacts madeand supporters recruited through NHS Change Day, new work in this areahas begun, for example in Dudley & Walsall where Open Minds AllianceCIC is working across mental health teams and their partners.

The overall success of NHS Change Day has provided an additional andunexpected impact for the work of Open Minds Alliance’s partners.“Being part of Change Day provided a greater level of credibility for ourwork,” says Kirsty Thomson, Head of Fundraising at Awyr Las GogleddCymru – a funder and close partner of Open Minds Alliance CIC. “To beable to talk to future supporters and to speak to our bosses about theimpact of the work – their ears pricked up when they heard it had beenpart of NHS Change Day.”

Lessons: Open Minds Alliance CIC is located in North Wales and AlysCole-King is based at Health Board within the Welsh NHS (not the EnglishNHS). While Open Minds Alliance CIC works extensively with the NHS inEngland, the Welsh team’s distance from London is one reason why theadvantages of being part of a single day of action stand out for the team.

“The national platform brings a heightened level of awareness andprovides a focus,” says Gavin Peake-Jones. “Change Day is something youcan’t avoid.” According to Kirsty Thomson there was also value inparticipating alongside others: “Seeing that there is a national ChangeDay was inspiring. Understanding that it’s not just people on the peripherywho want to make change happen but people throughout the NHS. Therewas a sense of solidarity – of not being on your own. Feeling part ofsomething bigger is a really important factor.”


NHS Change Day approach: Alongside the focus and solidarity created by asingle day of action, the team at Open Minds Alliance CIC was also struck bythe way in which Change Day gave permission for people to initiate andembed change. “The national day was symbolic – giving people the time andspace to think about the change they would like to make.”

In addition the structure of Change Day itself reflected a differentapproach to culture and organisational change that resonated stronglywith the approach of Open Minds Alliance CIC:• “The way in which NHS Change Day was formulated – peopleidentified issues for themselves and others could sign up or not – meantthat it was self-selecting. What came up were the issues that matteredto people.” (Sian Peake-Jones)

• “In the same breath as talking about the change we were also talkingabout being part of Change Day. It allows people to get on with thingsand breaks down barriers.” (Gavin Peake-Jones)

Although he now gives much of his time to Open Minds Alliance CIC,Gavin Peake-Jones has a professional background in organisational changehaving worked for the likes of Marks & Spencer and Ford as well asfounding a successful social enterprise. He saw NHS Change Day as a rareexample of a large organisation demonstrating that it understood thecomplexity of the change process “rather than seeing the organisation asa machine with inputs and outputs.” For Peake-Jones, “working withpeople at the grassroots to set strategy is critical.” This was one of thestrengths of Change Day as it enabled a flow of ideas between the peoplewho were pledging. In this way Change Day “created the right systemsand processes to enable the change to take place.”

Changes in thinking and leading: Open Minds Alliance CIC recognisethat as innovators they have tended to work in ways that are not

universally adopted within the NHS. “I’m an enthusiastic user of Twitter,”says Alice Cole-King, “which led to raised eyebrows from somecolleagues!” One of the successes of Change Day was that “it inspiredpeople who may not normally engage in social media. It showed how itcan enable individual nurses, physios – frontline staff – to collaborate.”

In addition the team itself valued the changes in their own thinkingprompted by their interactions with a whole new set of contacts as aresult of Change Day: “We’ve had people asking us challenging questionsand asking us to do things slightly differently. NHS Change Day has been acatalyst to broaden our thinking.”

Gavin Peake-Jones reflected that Change Day had the effect of generatingnew points of leadership in the NHS, of which Open Minds Alliance CICwas just one: “Change Day is a national initiative that gives us permissionto initiate culture change.”

It is perhaps not surprising that Open Minds Alliance CIC was able tomake such good use of the opportunities of NHS Change Day. After all, asGavin Peake-Jones says, “there is a campaigning quality to our work.We’re passionate about embedding change. We want to be that change.It’s not a routine job for any of us.” Or as Alys King-Cole concludes, “It’salso a very enjoyable activity. These are the things that motivate us whenwe go to work – making a difference for people.”

2.3 The Story of Derbyshire Community Health Services TrustThe pledge: The staff of the Derbyshire Community Health Services(DCHS) Trust made a corporate pledge to “identify and support InnovationScouts” through a local “NHS Change Week.” Individual and teampledges included pledges on Change Day and Change Week – and someare ongoing today.


The corporate energy for the pledge came from the Service Improvementteam who secured a Board commitment to support a Change Week tocoincide with Change Day. Led by Ian Murray (Head of ServiceImprovement & Innovation), Donna Clemens and Helen Short (ServiceImprovement Managers), the Service Improvement team communicateddirectly with the 200 voluntary Innovation Scouts asking them to makepersonal pledges for NHS Change Day and to recruit others in their part ofthe organisation to do the same: “the Improvement Leadership Trainingthey had all taken was voluntary so we already knew they were passionateand engaged about improvement and creative thinking. We knew most ofthem would say ‘yes’ – and they did!”

“We wanted to make sure that most people knew about Change Day,”explained one team member. “So we put together a PR campaign whichincluded email invitations to all staff to join in Change Day and ChangeWeek. The ‘comms’ team was great! We had a 10-day count down withdaily emails including the Change Day branding asking ‘what are yougoing to do to make a difference?’ and we highlighted the pledges thatthe Chief Exec and other members of the Exec Team were making.” Aspart of the PR strategy the Service Improvement team developed a ‘menu’of pledges which they encouraged staff to adapt, adopt or use as aprompt for their own thinking.

The Service Improvement team was keen to ensure that Change Day andChange Week fast-forwarded change in a sustainable way. They launchedthe ‘My Idea’ email address as part of the Change Day/Change Weekcampaign and most of the DCHS pledges were made using this route. Thismeant that all the pledges came through to a single point in the ServiceImprovement team: “It was important to understand who was makingpledges and where they were in the organisation. It meant that we wereable to provide support and enable corporate pick-up where appropriate.”

The team created a local ‘pledge wall’ and all the DCHS pledges wereuploaded to the national NHS Change Day website.

One Innovation Scout on each of the Trust’s sites volunteered to raiseawareness of Change Day and to promote it amongst teams. During Change Week they were asked to make themselves as visible aspossible to encourage people to make pledges.

Why this pledge: DCHS has taken a proactive approach to supportinginnovation for a number of years. A survey identified that staff oftendidn’t know where to go or what to do with their ideas for innovation andchange. DCHS therefore developed an innovation infrastructure whichincluded identifying volunteer Innovation Scouts who were provided withImprovement Leadership Training. Innovation Scouts came from all partsand levels of the Trust and so could act as “the eyes and ears of theorganisation… if staff came up with an idea they would be the first pointof call.”

The Service Improvement team had aspirations to go further. They wantedto make it as easy as possible for members of staff to share their ideas andget the support they needed to make them a reality. The ServiceImprovement team therefore planned to launch a dedicated ‘My idea’email address with a commitment that each email would receive aresponse within three days including a short plan setting out the supportthey could provide.

Change Day “seemed like an ideal catalyst and was a driver to publiciseand fast-track some of the things that we were already thinking about.We brought things forward because Change Day created a deadline.We thought ‘let’s get it done for Change Week’ so that we can promotea full end-to-end model that people can have confidence in.”


How DCHS got involved: Members of the Service Improvement teamresponded to early adverts for NHS Change Day and brought it back tothe team and organisation. The team saw NHS Change Day as an“exciting opportunity to motivate and engage staff in innovation andchange.” In particular the team viewed NHS Change Day as a way to“mobilise and motivate” the 200 Innovation Scouts already developedwithin DCHS and to “to get them to influence harder to reach groups.”

Outcomes: In total over 500 teams and individuals made over 150different pledges: “Big themes appeared around talking and listeningmore; with patients and with staff. Seeing things from different anglesand perspectives to ensure we are managing our staff in the best way anddelivering care in the way our patients want. This has lead us to having adrop-in at our AGM where we will be asking patients about the best wayto communicate…what they think about our services which isn’tnecessarily a complaint or a compliment, this could simply be small thingsthey think could make a difference.”

The Harlem Shake: DCHS Healthy Work Champions in the Health RecordsTeam at St Oswald’s Community Hospital pledged ”to be active in ourworkplace as part of our health and wellbeing.” During Change Weekthey ran a range of drop-in activity sessions for staff which ranged fromyoga to Nordic walking. To promote this pledge and encourageparticipation in the sessions they made a video of themselves doing theHarlem Shake which they posted and which became a local sensation withover 2000 hits. Not only did this help to bring 100 people to the sessionsit also helped to create a buzz around Change Day in DCHS. “All in all thiswas definitely worth doing and worth all our hard work and effort, andfrom the feedback we have received from staff they all really enjoyed it,and were very grateful to us for giving them the opportunity to get

involved, look at new things, and really take a look at themselves (whichwe don’t very often have time to do),” Nicola Shaw, Medical Secretary.

Podiatry Services: Danny Connor, Podiatry Manager, pledged “to obtainpatient questions via video and play at team meetings to discuss feedbackand communications to patients/service users” as a way of enablingpatients “to tell their own story, in their own words, in their own way.”Staff reported that sharing the experience of patients in this way “broughtpatients into the room… ensuring that patients remain at the heart ofwhat we do.” As a direct result of video shot during NHS Change Weekthere have been improvements in signage, patient information andnotification.

The team now embraces this way of capturing the patient experience:video items have become a regular feature of agendas and videos areshown quarterly at team meetings. Video replies from the PodiatryManager responding to patients’ ideas, observations and questions arealso provided “to present a ‘face’ to the public (as opposed to the facelessmanagement!)” There are now plans to roll out this approach to capturingpatient experience across DCHS. DCHS is also looking at other ways todevelop this pledge such as filming staff with questions for governors andmanagers to be discussed at leadership and staff forums.

The ongoing impact of Change Day can still be felt at DCHS: “We’ve gotinitiatives that have happened and are continuing as a result of ChangeDay. It allowed a bigger footprint of opportunity within the organisation tohave permission to make a difference. It allowed people to channel ideasthrough a framework. Before, they might have been lost or forgottenbefore they had been able to grow. People now know where to go forsupport and we can help nurture them.”


http://www.youtube.com/watch?v=8GlwQfk7N68

http://www.youtube.com/watch?v=8GlwQfk7N68

The Service Improvement team have been continuing to support many ofthe Change Day pledges through their ‘Let’s Keep it Going’ programme.This has included visiting teams and individuals who made pledges todiscuss sustainability and to identify barriers and blockages. Change Dayhas become part of the improvement and innovation landscape at DCHS:“We keep talking about Change Day and feature it in our Trust commsflyer to celebrate what we’ve achieved. The Chief Exec mentions it inemails. The scene is being set for next year!”

Lessons: “The amount of effort that went into putting an effective PRcampaign together beforehand. We are a big organisation with over 4500staff. Getting the message over in as many different ways as possible wasfundamental to making sure that people got involved.

“We needed to make it as easy as possible for people to pledge – e.g. havingthe menu of pledges to sow the seeds which really increased take up.

“When we first heard about Change Day we thought it was a brilliantidea but in some parts of the organisation there was a kind of ‘so what’concern asking ‘what does it do for longer-term change and improvementand change at scale?’ So we had to think about how we could make surethat it wasn’t just one day without any measurable impact. Having thepledges channelled locally meant they could be followed up after ChangeDay and in some cases developed from local to corporate pledges.

“It remained entirely voluntary – the spirit about it is wanting to make ateam or an individual difference. I truly believe that for serviceimprovement one volunteer is better than 10 pressed men.

“Where there is something a bit different you start with the people whoare most committed and then you get some momentum which brings theuncommitted and then even the most resistant.”

Changes in thinking and leading:“We seem to be coming out of a culture where we’ve found we’ve had toovertly give permission for staff to make a difference. In our ImprovementLeadership Programme we say ‘if you need it this is the permission tomake a difference’ and people say ‘oh, right, OK. We didn’t know wecould do that.’ NHS Change Day did that too.

“For the NHS, Change Day was a little bit different. To bring it into theNHS had some foresight. But it was simple – it didn’t require complexmobilisation; you could think about your pledge on the day and then carryit out. You can make a simple pledge that will make a difference to asingle patient or a cohort of patients.

“Pledges were made where you think ‘we should be doing that anyway’but in a lot of cases we don’t. It helped to bring you back to basics.

“It influenced the approach of managers and showed them the skill andcreativity they have in their teams. It demonstrated that people at thefront of their teams know their business better than others e.g. themanagerial support for the Healthy Working initiatives – I don’t think thatwould have happened before.”


2.4 The Story of Steve Fairman, NHS EnglandThe pledge: Steve Fairman, the Director of Business, Improvement andResearch for NHS England, pledged to spend a day shadowing a GP, JamesGray, in Sheffield; and he asked James for a reciprocal pledge to shadowSteve for a day.

Steve spent a day in June with over 100 patients who came into contact withmembers of James Gray’s general practice team. Throughout the day, Steveshadowed two receptionists, a GP responsible for telephone triage, a GPconducting home visits, and a GP doing in-patient surgery. He also shadowedthe practice manager. “I saw all ends of the spectrum in a single day.”

GP James Gray and practice manager Joanne Marshall now plan to shadowSteve for a day. “I don’t want to make it easy for them; they are going to getthe nitty-gritty. They will be here when I have corporate decision-makingwork. They are going to see that I spend a lot of time video-conferencingbecause I can’t be in two places at once, and that is what a national jobdemands. It is a very different way of working than on the frontlines.”

Why this pledge: Although Steve had been aware of NHS Change Day formonths, he had not committed to a pledge that was meaningful to him untila few weeks before Change Day. “Over the years as my career developed Igot further and further from patients. I wanted to do something that wouldengage me with the patients and also provide a reciprocal lens for someoneelse to see what it was like at my end of the NHS.”

How Steve got involved: Steve was first exposed to NHS Change Daythrough his work with Helen Bevan on the Change Model and was a part ofthe NHS Change Day Expert Oversight Group.

Outcomes: “People have asked me: What was the point of my day inSheffield? What has changed as a result? For me, my attitude has changed.But I can’t show you that on a graph or a run chart. It will manifest its impactbecause other people hear what I say or because I develop a relationship in adifferent way or because I argue a point more persuasively by drawing on myexperience. Some people need numbers to understand change. I started mycareer in information management, and I appreciate the numbers. But I’vemoved on from that.

“I lead a lot of leadership development programmes for the NHS, and mypledge has armed me with real life examples. I used to put up PowerPointslides with data and evidence and walk through them. Now I put up the sameslides and call on my experiences with GPs and patients to illustrate why aparticular idea is important…

“For instance, when I put up a slide that says ‘patient expectations are rising,’I can tell the story of Mr. Jones. James and I visited Mr. Jones at his home andfound him lying on a sofa in the corner of the room watching television. Mr.Jones did not greet James as his doctor but instead jabbed his finger at thetelevision and asked James whether he watches Embarrassing Bodies (the TVshow). James said no. Mr. Jones said, ‘Well, I have exactly what the guy onlast week’s show had, and I know exactly what needs to be done about it.’ Isaw how Mr. Jones’ expectations affected his encounter with James, theirrelationship and the care he received. I realised how hard the work of the GPis in dealing with those kinds of expectations before an exam has beencompleted.

“I also tell people about Mr. Smith. While I was sitting with another GPbetween surgery appointments, the phone rang from reception. ‘Mr. Smith ishere, can you see him?’ The GP said yes, send him in. Mr. Smith did not have


an appointment. He was in his early 80s and had dementia. The practiceagreed that they would care for him even when he turned up on the wrongday to see his doctors. They agreed that whoever had space would find timeto see him. They also agreed with Mr. Smith’s daughter that they would writeany instructions for care on a brightly coloured card and put it in his toppocket. She agreed that she would look for the cards and follow theinstructions. On this day, Mr. Smith needed long socks and cream for a soreon his leg. I tell this story to demonstrate what a dementia-friendly practicelooks like.”

Lessons: “I was surprised at how profound an impact my pledge had on me.I didn’t expect to learn many of the things that I encountered. For example, I learned about the – sometimes directly conflicting – incentivesof ownership in GP practices. GPs are partners in small businesses. They allhave a vote, and unless they all agree to something within their group, thepractice as a whole cannot change.

This [approach] has potential to create a significant, even if not alwaysintentional, blockage to improvement.... There is a tension in having theincentives of small businesses play such an important role in the NHS. If we want to improve, we have to change the incentive structures.”

Changes in thinking and leading: In his day job, Steve is responsible fordeveloping transformational healthcare change programmes at a nationallevel. He has a varied background extending from academic social research tohealth economics to demographic forecasting. He is also responsible forhelping develop a better evidence base to inform future NHS-wide decisions. In Steve’s words: “Now that I know more about what happens at thefrontlines, I ask myself: ‘What are the gaps in knowledge that frontlinepractitioners would find helpful if they could commission research on it?’

I am involved in a piece of work to identify research priorities from clinicalgroups across the country, and I have asked two GPs from Sheffield to takepart because I want their views to be heard. They believe they can do things in primary care that are currently being donein secondary care. Initial studies suggest that they are right.

“My team needs to bring this kind of credibility to our work. It comes fromunderstanding what people at the front lines are doing and the issues theyare facing.

“I now seek out this kind of thing. For example, I work with a graduatetrainee. Usually she comes to my office, and we discuss issues pertaining towhere she works, the people she works with. I decided to take the train toLondon to visit her at her hospital. Now I understand who her people are andwhat her building looks like, and I can empathize when she tells a story. It isimportant – not only to her training, but to the outcome of our relationship –that I made this effort to understand her experience.”

NHS Change Day approach: “Change Day is a very important part of theNHS. If we all have tools for change in our tool bags, as it were, Change Dayis a very important tool. It’s not a tool that everyone will want to use. I askedmy own team to make pledges, and not all of them did. I understand; it’s nothow most people in the NHS think change happens. I have many traditional-thinking people on my team. Change Day is not their thing. They wouldrather do some lean thinking down the corridor. But Change Day is aboutdoing something differently.

It’s not an expert telling you the best way to change; it’s not a consultantworking with you to create change. It’s about people seeing things from theirstandpoint and saying: ‘I am going to change that’.


“I was so pleased that it came from the bottom up way of thinking aboutchange. Change Day empowers individuals in the NHS – and there are anawful lot of them – to make change happen, no matter who you are.Look, if half a million NHS staff commit to Change Day 2014, they aremaking a powerful statement that the NHS needs to change. Half amillion people can spread the word about Change Day to everyone theygo home to. One of the potential sources of Change Day’s power is that itis building a base for change.

“I have noticed that the reports about Change Day highlight numbers:how many people did this, how many Tweets, how many pledges, howmany organisations, how many chief executives. Are they responding tothe critics who want to see measurement, metrics, impact? I don’t know.But it leaves out the bigger lesson that we can learn from Change Day. It is about leadership.”


Whizz Kidds featured on NHS Change Day at Healthcare Expo

CHAPTER 3: LEARNING FROM NHS CHANGE DAY 2013

3.1 ‘Impact’ or ‘Design & Outcomes’?There is considerable debate about the ‘impact’ of NHS Change Day.There are those who have been decidedly sceptical arguing that withoutfirm data showing the link between Change Day and an improvement inpatient care or specific cost saving, it is not possible to call Change Day asuccess. It is certainly true that while there are many examples of specificimprovements detailed in this report and associated case studies, NHSChange Day 2013 was not designed in a way that would allowmeasurement against traditional improvement metrics. The appropriateplace for traditional improvements metrics to emerge within Change Dayis at the level of pledge-makers, and it is thereby a voluntary activity – aspart of a pledge.

Those involved in the design of NHS Change Day 2013 do not shy away fromthis criticism and readily admit that “if you want evidence of direct patientchange that is sustained I suspect there is not a lot” (Damian Roland). Thisvery issue was debated among the core leadership early on, and theyintentionally pursued a strategy that gives people the option to choose thenature of their pledge, instead of signing onto one or two specific pledgesthat would take on the quality of a national campaign (and measured moretraditionally). Thus the number of pledges alone is not so much evidence ofchange but the impact of reach in using social media.

The Change Day leadership team sees the emphasis on pledging – instead ofacting on a pledge – as an area for improvement. “It is one thing to pledge, itis another in terms of what difference it made,”points out Helen Bevan. “Wedon’t have conversion rates. What percentage of pledges made converted to

action? When you talk to people in the voluntary sector, they have aconversion rate for pledge-based campaigns. The fact that so many peoplepledged was important, but we have to understand a lot more about whatimpact it had for patients and the system as a whole.”

The core team has been examining the patterns in the 2013 pledges inorder to develop metrics for 2014. They recognize that many moreelements of Change Day can be measured, such as impact measures frompledges or on the effects of pledges on involved patients and staff. Forexample, since many pledges in 2013 suggested that participation arosefrom a commitment to the values of the NHS, and that involvement wasintrinsically motivating, Change Day 2014 could assess whether ChangeDay contributes to motivating staff in their jobs. It might also be helpful tomeasure the impact of pledges on organisations in the system. For example, Hertfordshire Community Health Service Trust used ChangeDay as an opportunity to bring together clinicians from across their systemto review the paperwork that they are required to complete, resulting insignificant changes to the entire reporting system. In addition, ChangeDay 2014 can track the conversion rate of pledges into actions.3

Beyond impact measures, developing metrics that reflect the uniquecharacter of NHS Change Day is both possible and desirable: NHS ChangeDay 2014 can embrace its unique design by quantifying how it works. For instance, it is important to count how many pledges came fromfrontline staff and patients, as well as senior leaders as an indicator of theeffect on distributed leadership.


3 The NHS Change Day team already has plans to make it easy for people to pledge and report what happened. Pledge-makers will get a text message that reads: ‘Did you do it? How did it go? What happened asa result?’

Measuring how many people told an online or on-the-ground narrative tomobilise others as part of their pledge would provide evidence of the levelof new capacity developed through NHS Change Day. Similarly, countinghow many new relationships were built through Change Day is animportant indicator of success.

Quantifying the design elements of the Change Day approach helps tells thestory of how it enables distributed leadership, commitment, and boundary-crossing relationships to innovate around patient care – and contribute toother ongoing organisational challenges.

Measuring the impact of specific pledges – and collecting evidence aroundthe outcomes of the Change Day design – cannot be understated. But despite the prevailing culture of evidence-based activity in the NHS, anabsence of impact measures is not in itself an indication of the success orfailure of NHS Change Day 2013. Change Day did not set out to be atraditional improvement programme. On the contrary, it was deliberatelydesigned to be something new; a movement of people within the NHSmotivated by shared values and a commitment to the possibility of changeand improvement. As one leading participant puts it: “For this sort of thing Ithink it would be counterproductive to try to measure the direct impact ofthe interventions” (James Haddow). Another adds: “The greatest success


Core leadership team members on NHS Change Day

we had was getting people involved in something that just wouldn’t havebeen possible a decade ago, five years ago – maybe even two years ago”(Damian Roland).

The design of NHS Change Day inevitably shaped outcomes that wereachieved. In this chapter we look at that design and consider the range ofoutcomes that flowed from it, the challenges and limitations that emergedand opportunities for development in the future.

3.2 Design: NHS Change Day, Social Movements and HierarchyNHS Change Day did not emerge from nowhere. For over ten years anumber of leaders in the NHS have been laying the groundwork for thedevelopment of a social movement principles to improving health care.This included engaging with and adapting insights from social movementtheory and research, developing skills used in community organising anddeveloping a ‘Call to Action’ framework used to mobilise action on criticalchallenges (Bate, Bevan and Robert, 2006; NHS Institute for Innovationand Improvement, 2011). This activity led to success but on a small scale;the next challenge was to deliver change across a whole system.

Yet by no means did all the members of the Change Day core teamparticipate in this prior activity. Having recently completed the intenseyears of clinical training, emerging leaders like Stuart and Damian wereentering practice, dissatisfied by what they found. They had an appetitefor learning from leaders of great social movements, people who had fewresources, and no hierarchical or positional power, but delivered results bybuilding power through collective action.

While learning from social movements, these change agents within theNHS also engaged creatively with the hierarchical structures in which theyoperate. The design of NHS Change Day is unique precisely because it is asocial movement approach that is consciously empowering people at the

frontlines to take action while at the same time engaging hierarchicalleaders. In their own words the NHS core team sought to make “the bestof both networks and hierarchies, working through informal networks andcommunities of interest and creating a genuine grassroots movement atthe same time as enabling leaders with positional authority to role model‘change leadership’ in a new way” (NHS Improving Quality, 2013). As Jackie Lynton puts it: “It was important to work with the hierarchy atan early stage. I sought the support of Jane Cummings, Bruce Keogh,David Nicholson and Miles Ayling, who were all massive supporters butrespected the grassroots nature of Change Day.”

The innovative design of Change Day resulted in a particular set ofoutcomes (as opposed to metrics) that we consider in this chapter. We explore outcomes that resulted from design elements including adistributed leadership model, an emphasis on building relationships,taking voluntary action, mobilisation around shared values, collectiveaction, social media, support from the ‘grasstops,’ and networks. We consider the strengths, challenges and limitations that emerged andopportunities for development in the future.

3.3 Outcomes: Distributed LeadershipDistributed leadership is already a familiar concept in public, private andvoluntary organisations. There is no single definition, but it is broadlytaken to describe leadership as something that arises from the behavioursand actions of an individual anywhere in an organisation rather thansomething associated with a position in a hierarchy. Structures ofdistributed leadership aim to create many ‘leaders’ throughout anorganisation who are capable of taking action on their own initiative whilewelcoming a high level of personal accountability (Northouse, 2013: 289;Wise, Woods and Harvey, 2003: 7-9). Social movements, which relyentirely on the voluntary commitment and resources of their supporters,exhibit many of the characteristics of distributed leadership.


The structures and process of the NHS, with its clear hierarchies and culture oftargets and top-down accountability, is clearly a very different kind of anorganisation. Indeed, it is striking how often those we have interviewed havecommented on the extent to which their NHS colleagues feel that they needto have ‘permission’ before they can change something or make animprovement. Having observed this pattern of behaviour among staff, JackieLynton commissioned a cartoon for Change Day that captures the prevailingculture of staff seeking permission to take action:


Comparison of hierarchy leadership model andinterdependent leadership model

Traditional Structure

Distributed leadership

NHS Change Day was explicitly designed to challenge this culture and tocreate opportunities for people throughout the NHS to take actionwithout having to ask for permission.

This design was reflected in the decision not to have a single pledge thateveryone would be asked to adopt. “One of the core values of the NHSChange Day was inclusivity and empowerment of the frontline ratherthan imposing or dictating what people on the frontline should do…[wewanted it to be] an empowering experience based on social movementtheory where people would be connected through their core values. Youcan’t do that if you tell people what their core values should be” (JamesHaddow). Instead, a group from the frontline got together to makesomething happen and invited others to contribute their own ideas andenergy to the collective effort.

This design principle had one very specific outcome: it created space forthe individual motivations and insights of NHS staff to be expressedthrough a rich variety of pledges. As Damian Roland puts it, “there wereno rules – it was simply ‘make a pledge’.”

Each Change Day pledge reflected an individual’s priority for changeresponding to his/her own local context and personal gifts andmotivations. This would not have happened if Change Day had beendesigned differently. As Liz Saunders, then at the King’s Fund and nowat the Hay Group, reflected, “NHS Change Day gave permission forpeople to go where their passion is. In the NHS we often look for changeto a particularly end, for example to reduce waiting lists or improve aparticular pathway. This doesn’t tend to lead us to the unexpected, orthings that might improve patient experience. What about baking cakes

with your patients? It might be really effective but unlikely that you’d begiven the time in regular day to day. Where do you get time to think thatstuff up? Change Day created that opportunity.”

This design principle was echoed in the approach taken by a number ofpledge-makers. The teams in Birmingham City Hospital (see AppendixB) and Derbyshire Community Health Services (DCHS) (see Section 2.3)were aiming to mobilise colleagues across their organisations. Bothteams considered and rejected the idea of pursuing a single pledgeprecisely because they wanted to stay true to the spirit of NHS ChangeDay. As a result, DCHS generated over 150 different pledges from 500teams and individuals.

For some pledge-makers the central objective of NHS Change Day – withits emphasis on mobilizing a movement for change across the NHS basedon the belief that everyone has a contribution to make – was itself amotivation for getting involved. This approach mirrored the values andbeliefs of Open Minds Alliance and the U Can Cope campaign perfectly(see Section 2.2). “We were attracted by the fact that this was agrassroots initiative,” explains Gavin Peake-Jones. “People at the frontline doing one thing together.”

Ironically, some staff may have seen NHS Change Day itself as providinga kind of hierarchical authority – but one that offered agency to them.Alys Cole King, Consultant Liaison Psychiatrist at the Betsi CadwaladrUniversity Health Board, observed, “People in the frontline can think thatthey can’t change anything. People wouldn’t have had the confidencebut because it’s part of Change Day it sort of gave them permission.”


Challenges of distributed leadershipApplying distributed leadership was not without its challenges. Withinthe core team, which actively tried to model distributed leadership, thiswas sometimes felt acutely. “The concept of distributed leadership wasnew to me,” explains Damian Roland. “But it wouldn’t have worked ifwe had said ‘this person is in charge.’…Sometimes it was messy,especially around decision-making; but our trust got us through it.”As members of the core team readily admit, there were times when theyreverted to more closed leadership styles – and that was when they ran intotrouble. Finding the most effective way of ensuring a constant flow ofinformation through the core team and out to key activists was a particularchallenge: “We couldn’t always tell what the core leadership team wasdoing… It was very difficult to engage with them, to push out the messagesand to get others engaged at the right time” (Pollyanna Jones).

Creating a structure for distributed leadership early on can help whenchallenges arise (as they inevitably will). Core team members readily admitthat beyond their central team, they failed to develop other distributedleadership structures to support Change Day engagement across England.For Change Day 2014 there are already efforts to develop a geographicnodal distributed leadership structure, so that leadership moves from onecentral Change Day team to many teams across the country working toengage their networks. This reflects the determination of the NHS ChangeDay team to continue to learn and to model the behaviours that they areencouraging others to demonstrate in order to develop greater capacityfor action. By taking this approach, they are offering a kind of leadershipoften seen in social movements: enabling others to exercise leadership toachieve shared purpose (Ganz, 2010: 509).

3.4 Outcomes: Building RelationshipsSocial movements rely on the strength of the relationships between theirmembers for their effectiveness. Relationships build movements andsustain them when they face difficulty or defeat; it is through relationshipsthat new members are recruited; and it is because of relationships thatnew resources are made available. This is why community organisers andother social activists put so much time into learning and teachingrelationship building (Ganz, 2010: 514-515).

Social media played such a central role in enabling the growth of NHSChange Day that it can obscure the offline relationships that underpinnedthe whole effort. In fact, the importance of relationships to NHS ChangeDay can be seen in every stage of its development.

BeginningNHS Change Day has its roots in relationships between people like HelenBevan and Stuart Sutton, and Jackie Lynton and Damian Roland. It wasn’tjust that each saw something in the other that inspired them; it was alsothat each one had resources that the other lacked. Through theirrelationship new resources were made available for shared action. As theybegan to explore taking action together, Stuart and Damian brought inother emerging clinical leaders; Helen recruited Jackie and otherimprovement leaders; and so it went on. Old relationships were deepenedand new relationships were forged. As Jackie Lynton puts it, “It startedwith a belief in each other…It is using each other and how we’ve beenable to capture each other’s energy. Some of us didn’t even know eachother before we started!”


SustainingNot surprisingly getting NHS Change Day off the ground was not withoutit’s difficult moments. At these points the investment in buildingrelationships paid off: “We built trust on our team by buildingrelationships around our shared values” (Damian Roland).

RecruitingThe early growth of NHS Change Day was based on relationship building.As Alan Nobbs recalls, “I remember sitting in a meeting in a grand room ina grand restaurant with Stuart Hill and Stuart Sutton and saying that itwas not enough to send emails, we have to build one-to-one relationshipsand connect to shared values. Stuart Sutton said that until we talk topeople, nothing will happen. Once we moved from the theoretical to theactual – that is when we got some momentum.” This momentumincluded directly recruiting colleagues from around the country to take alead, make a pledge and recruit others to join them.

Pledge-makers Ellie Milner and Harry Giles had this experience atBirmingham Children’s Hospital (BCH) (see Appendix B). As PatientExperience and Health Promotion Workers, their day jobs took them inand out of the wards; and both had good relationships across the hospital.“When they were doing their ward visits they would talk to the wardmanagers about Change Day – and talk them into taking the posters andthe pledge slips,” explains Janette Vyse the Patient Experience Lead atBCH. “Ellie’s personal experience fires her passion and Harry is very bubblyas well – that really helped!”

Eventually the relationship building hit a critical point and NHS Change reallybegan to take off. “What heartened me,” recalls Liz Saunders, “was when I


The nature of relationships in social movements (Marshall Ganz)

got a call from a manager in Cornwall who had got the NHS Change Dayvideo but not through me. It became clear that nobody had control ofChange Day anymore. It felt a bit dangerous but in a good way!”

Relationship-building not only enabled NHS Change Day, it was one of itsdesign principles. As a result, a host of outcomes were achieved thatwould not have been possible with a less deliberately relational approach.

Michaela Firth, one of the members of the Core Team, identified newrelationships as one of the most significant outcomes of NHS Change Day:“The core team built relationships with one another, and now we usethose relationships as a resource. There is an immediate group of peoplethat we can go to for direct support because we have a shared feeling ofwhat we did together. I now call on at least 35 people that I didn’tbefore.” This was far from an isolated experience. As Joe McCrea puts it,“We provoked conversations and relationships between different groupsof people in different parts of the NHS that will make lots of little changesthat will build up to a big change.”

Some of the outcomes from this relational approach are intangible, but noless valuable for that. Liz Saunders reflected that, “Change Day gives ussome of what we need. The benefits that people get from being incommunity with one another are huge – to have that network. We get somuch from just being with each other.”

Because it was designed to be relational, NHS Change Day developed newsocial capital – and capacity. This took the form of new relationships whichnot only have an intrinsic value for the people involved and a widerbenefit for the NHS, they also provide the new resources on which NHSChange Day 2014 can draw.

3.5 Outcome: Weak Ties & Strong TiesNHS Change Day was in part sparked by the opportunity for individualsfrom different parts of the NHS to connect with colleagues with whomthey might never have normally come into contact. This included, inparticular, emerging clinicians, managers and improvement leaders. From the outset, therefore, NHS Change Day was able to draw on whatMark Granovetter famously called “the strength of weak ties” – in otherwords, the connections between people who are in some important waydifferent from one another (Granovetter, 1973). This difference providedheterogeneity that ensured that new resources, insights, knowledge and– very importantly – contacts and networks could be combined. For instance, the presence of individuals on the core team, who workedat senior levels in the Department of Health, provided both importantinsights and opportunities to secure support and engagement. Equally important, the experience of practicing clinicians ensured thatNHS Change Day remained constantly in touch with the experience offrontline staff.

‘Strong ties’ are what Granovetter calls the connections formed betweenpeople who have some fundamental similarity (Granovetter, 1973). In theNHS these might include the common bonds that exist within professionalgroups (such as ‘doctors,’ ‘nurses,’ ‘managers’). While these can build apowerful sense of identity, they can also limit the capacity of initiatives likeChange Day to grow. If Change Day had been launched by ahomogeneous core team, its capacity for growth would have beensignificantly limited.


NHS Change Day created what one member of the core team called‘thousands upon thousands of weak ties at the operational level.’ This isan important insight and signals the potential role of the relationshipscreated through NHS Change Day in stimulating ongoing change longafter the day itself has passed. As the core team member went on toexplain: “Our job is to put in place a platform and tools where we donothing, but which enables other people to do it for themselves. That willenable change that we won’t even know is happening. We will provokeconversations and relationships between different groups of people indifferent parts of the NHS that will make lots of little changes that willbuild up to a big change” (Joe McCrea).

3.6 Outcomes: Voluntary ActionNo one has to join a social movement, and they can leave whenever theywant to. They are by their very nature voluntary. While many NHS staffregularly give much more to their jobs than their contracts require, theyare nevertheless employed to do a specific job. Moreover, the long historyof targets in the NHS and the more recent experience of reorganisationhas created an environment in which many are understandable suspiciousof yet another initiative being foisted on them. It is not surprising thenthat some people’s initial response when they heard about NHS ChangeDay was to ask, “what are ‘they’ doing now?”

The answer, of course, was that ‘they’ were not doing anything. The voluntary nature of Change Day changed both the way in whichpledge-makers were recruited, and the way in which they in turn couldrecruit others. Janette Vyse of Birmingham Children’s Hospital explainedthat it was a very different experience asking people to volunteer on thebasis of commitment rather than trying to get them to agree because they


Comparison of strong ties network and weak ties network

were being required to participate: “We were honestly able to say ‘wewould love you to!’” For Ian Murray of Derbyshire Community ServicesTrust (see Section 2.3), the voluntary nature of Change Day was crucial toits success: “It remained entirely voluntary – the spirit about it is wantingto make a team or an individual difference. I truly believe that for serviceimprovement one volunteer is better than ten pressed men.”

If the voluntary design principle changed the nature of the engagementfrom individuals and teams, it also changed the experience of bringingabout change in the NHS. As Liz Saunders remembers, “There is a feelingthat making change in the NHS is arduous. Here it didn’t feel like that…There was a sense of fun about it. It felt like it had a serious intent butwas approached in a lighthearted way.”

Joe McCrea similarly remarked, “By a country mile it is the most enjoyable,challenging, exciting, innovative, ground-breaking thing that I’ve beeninvolved in in ten years. My wife says, ‘I’ve not seen you bound out of bedat five o’clock in the morning because you’ve had an idea and want to goand talk to somebody… It’s taken ten years off you.’ It’s renewed myenthusiasm!”

Helen Bevan concludes, “It was the best example of volunteerism in theNHS. We never cracked it on volunteerism before… hierarchy trumpedvolunteerism. This time young leaders came because they were motivated,enthusiastic, and positive.”

3.7 Outcomes: Mobilisation around Shared ValuesSocial movements draw together people who share a sense that change isneeded – often urgently. In the face of an intolerable condition, action is

required. Joan Saddler, formerly the National Director of Patient and PublicAffairs at the Department of Health, points out that the Change Dayapproach was atypical: “Usually you’ll get the Save Our Hospitalcampaigns which will have thousands of people coming out. But to dosomething from the stance, ‘we love the NHS, this is already a greatservice, how can we improve it?’ I thought it was spot on.” In otherwords, Change Day was designed to mobilise action for continuousimprovement (positive) – not opposition to change (negative).The sense that ‘we love the NHS’ permeated the whole of NHS ChangeDay. Indeed, it is an expression of the shared values on which Change Daywas built. As Stuart Sutton explains, “In the spirit of volunteerism, wewanted to give people the opportunity to connect to why they chose tobe in the NHS... There is something more about working for the NHS. The NHS belongs to all of us – people who work in the NHS use the sameservices that our patients use. We all have ownership in the NHS.”

This focus on shared values led the NHS Core Team to spend timedeveloping their ability to communicate their values more effectively usingnarrative and story. Much to his surprise, Damian Roland found this apersonally transformative experience that made a major contribution tothe success of NHS Change Day: “The single most important skill I learnedfrom improvement leaders was narrative. If I heard myself saying this afew years ago, I would be laughing at myself. I used to think that peoplestanding up and telling ‘stories’ was ‘business babble’ basically and youdon’t really need it – you just need to get on and do things. But one ofthe fundamental successes of Change Day was that our personal stories –why we all made our pledge, or the reasons we were called to work forthe NHS – connected and motivated people. I am now a passionatebeliever in narrative. It will stay with me the rest of my career.”


Pollyanna Jones heard Damian using his newly developed narrative skills,crafting a ‘call to action’ around a challenge, choice and outcome:“Damian’s Call to Action is why I got involved. That’s why I trusted that hewould do a really good job and why I wanted to help out. It connectedwith my values. That shared value and belief in the NHS.”

Putting shared values at the heart of Change Day provided an authentic‘call to action’ to which others with a similar outlook responded. It madeChange Day not only an opportunity to do something that would be ofbenefit to others, but also to express support for the institution of the NHSand the shared values that it represents.

3.8 Outcomes: Collective ActionSocial movements rarely call for their supporters to take action alone.Being based on shared values, social movements are an expression of acommon identity and therefore naturally lend themselves to shared action.But collective action also has practical advantages. Working towards asingle event or goal has the effect of galvanising activity and focusingminds; it provides something to aim for and an opportunity to celebrateonce it has be achieved. By designing action around a single day, NHSChange Day was able to take advantage of all of these outcomes.

Gavin Peake-Jones of Open Minds Alliance (see Section 2.2) appreciatedthe galvanising effect of working towards 13 March 2013: “The nationalday was symbolic – giving people the time and space to think about thechange they would like to make.” For James Rowland, NHS Change Daywas reminiscent of Comic Relief: “People who participate in Comic Reliefall feel part of one cause even though they are split across geography andsocial class – that one day they all come together and feel part of it. That feeling of being part of something bigger was something Iexperienced. Knowing that several thousand other people also doing it.”


Public narrative – Self , Us and Now (Marshall Ganz)

Organising for action

Mobilising collective action develops feelings of ‘YCMAD’ – i.e. ‘you canmake a difference’ – feelings that motivate people to exercise leadershipagain in the future. It creates natural opportunities for leadershipdevelopment that feed a virtuous cycle. “The majority of people wouldn’tcall it ‘leadership,’” remarked one pledge-maker, “but each pledge is aleadership opportunity. So even if people think ‘I am not a leader, they arestill exercising leadership by making good on their pledge.” Or as anotherpledge-maker put it, “If you’ve got five other people on your pledge, theyare all involved in a shared purpose – you have them on board toward asingle goal. That is what the NHS Change Model is. So when you comeout the other end, you managed to join a movement of collective action,and maybe even lead some people yourself through a shared purpose –and you may not even realise that’s what you’ve done!”

3.9 Outcomes: Use of Social Media4

Events of recent years have demonstrated the powerful use that socialmovements can make of social media. The ability for people to connect,exchange ideas, support each other and ultimately mobilise has beenillustrated in all parts of the world and in a wide range of circumstances.However, NHS Change Day may well be one of a few examples wheresocial media has been used by employees to self-organise – not in protestbut in order to take positive action.

TwitterNot only was NHS Change Day born out of a Twitter conversation, butTwitter went on to play a critical role in the growing and sustaining thework. The Change Day twitter feed ultimately reached over 12 milliontwitter impressions.

For some pledge-makers Twitter was integral to both the design andsuccess of their action. Alys Cole-King, Consultant Liaison Psychiatrist atthe Betsi Cadwaladr Health Board and founder of the Open MindsAlliance, used NHS Change Day as a way of growing support for the UCan Cope suicide reduction campaign (see Section 2.2). The pledge wasdeliberately crafted so that it would appear in a single tweet – the aimbeing to secure as many re-tweets as possible. Having posted the pledgeon 8 March, one week before Change Day, Alys Cole-King drew on herwide network of contacts and Twitter followers to begin to recruitsupporters. “We actively used social media,” explains Sian Peak-Jones(Open Minds Alliance Operations Director). “We used Alys almost as abrand and deliberately tried to develop her Twitter following.” Cole-King’spledge ultimately achieved 58,000 supporters – more than any other NHSChange Day pledge.

Twitter was a social media tool perfectly suited to both the needs andthe spirit of NHS Change Day. It’s somewhat anarchic, unregulated anddemocratic culture mirrored the kind leadership and action that theChange Day Core Team were hoping to stimulate. As one closer observernoted, ”Twitter helped! No space to publish guidelines. It’s just a spacefor ideas” (Liz Saunders).


4 Lynton and McCrea, 2013.

If Twitter played a major role in the success of NHS Change Day, it alsohad its limitations as a communication tool: “cascading informationthrough Twitter was not enough” reflects Pollyanna Jones from the NHSChange Day core team. As the South Warwickshire CCG Change Dayteam discovered during their pledge, Twitter, websites and online surveyscannot replace the understanding that comes from face-to-facerelationship building (see Section 2.1). For them, one key takeawayfrom their pledge was that there is no substitute for buildingrelationships with people like Health Champions.

Yet at the same time, like the national Change Day core team, the SouthWarwickshire CCG team employed Twitter, video clips, local press, and awebsite to generate awareness of their pledge and Health Champion

programme, thereby going from touching 450 people in face-to-faceencounters to thousands of people across the area. Each tool has itsplace; and the key is knowing to use which approach, and for what end goal.

YouTubeThe NHS Change Day Core Team and pledge-makers throughout theNHS made fantastically creative use of the YouTube. A YouTube channelwas established that both broadcast videos created centrally and actedas a central point for sharing material created on the ground. In just 20days before 13 March the channel built an audience of over 3,000 viewsfor over 25 videos. The most popular YouTube video (1,272 views) was aChange Day jingle written and performed by staff at Harrogate Hospital,which reportedly had staff dancing in the corridors when it wasbroadcast on hospital radio.

In one case the making of a video was itself used as a tactic for buildinglocal support. The team in St. Oswald’s Hospital in Derbyshire made apledge to ‘get staff more active in the workplace’ and decided to videothemselves doing the Harlem Shuffle (see Section 2.3). The filming datewas advertised on the staff discussion forum to encourage other staffacross the organisation to join in on the latest internet craze and make apledge too. When it was posted on the Internet the film generated over2000 hits.

WebThe NHS Change Day website on which pledges were posted andsupporters logged was built with very few resources using the existingsystems that were available. As a result it was far from perfect and wasfrequently mentioned as one thing that the core team and other


participants would want to change in the future: “It was not what weneeded and I think we could have engaged many more people if we hadhad what we needed. I fielded so much criticism from my colleaguesabout the website… and I was quite frankly embarrassed about that”(Damian Roland).

Nevertheless, the website did make it possible for people from across theNHS to communicate with each other around specific pledges. Its valueshould not be underestimated as a means of building connections, asense of shared purpose and solidarity. For Joan Saddler, currentlyAssociate Director at the NHS Confederation, this was a significantoutcome of the whole Change Day experience: “You had a range ofpeople popping up on your screen who would say ‘I’ve seen your pledge– it’s fantastic!’ They’d just be coming out of the woodwork and say,‘really liked that, really well done.’ It made connections in that verysimple way – and I met people through Change Day that I would neverhave met otherwise.

“It also created a network of people who were part of a public NHSsecret…’ I was part of Change Day – you were too, weren’t you!’”

Ultimately, with all its flaws, the NHS Change Day web presence was theway in which the growth of Change Day could be observed. This provided a practical way of measuring success and, just asimportantly, it created moments of hope and celebration. “When westarted to see the pledges coming in thick and fast in the week runningup to NHS Change Day, and then when we smashed our target, I didn’tneed to hope any more because we’d already done it!” (James Haddow).There are plans in place to ensure that NHS Change Day 2014 has astronger online and social media presence, including a seamless web,mobile and social media strategy. As Joe McCrea observes, “Let’s not try

to do loads and loads of different things and lose the focus. Let’s makeit bigger and better and easier for Change Day to do what it didbrilliantly the first time around.”

3.10 Outcomes: A Special Kind of Grasstops LeadershipChange Day may have been led by the grassroots, but it was a unifyingforce that unearthed the convergence of shared purpose across seniorNHS leaders and policymakers, and local managers and front line staff.Many senior leaders made personal pledges to Change Day. For example, David Nicholson pledged: “I will do the education andtraining associated with becoming a ‘Dementia Friend’ so that I can inmy own working life, and in my life outside of work, make acontribution to improving the life expectancy and services that peoplewith dementia receive… I also pledge that as NHS Commissioning BoardChief Executive, I will do everything I can to ensure that more and morepeople who work within the commissioning board make the dementiapledge. It is very important that everyone who is a part of the NHSCommissioning Board make a pledge as part of NHS Change Day.”

This is an important design element to a “leaders everywhere” model.“[Senior leaders] of course should engage with [Change Day] likeanyone else. They should in fact create the conditions that allow it tohappen. But if a Chief Executive starts saying, ‘We’ll do NHS ChangeDay, but only if I see X pledges come from this group of staff, or fromthis organisation,’ then they are corrupting it” (Liz Saunders). There isunquestionably an important role for senior leaders to play in amobilisation like Change Day, but it is not necessarily the role that manyare used to playing.

This message to senior leaders came in part from the core leadershipteam. They did not seek permission from senior leadership to run or


launch Change Day. They decided collectively to do it and used whatresources they could find. For instance, they needed a web platform tohost the online “Pledge Wall” for people to post their pledges for action.They identified an existing website that they could adapt. It was notideal because there was a complex registration system required forpledge-makers to access the system; and as a result a large number ofpledges were not posted. But it worked well enough and taught theteam what resources would be helpful in the future. In the end it wasmore important to build the spirit of volunteerism than to seek formalresources from line management. In well-organised change efforts,“resources get attracted, not allocated.” The core leadership team’sexample modelled (both to the grassroots and to senior leaders) the role that senior leaders were expected to play – the same one aseveryone else.

One lesson for senior leaders comes from Helen Bevan’s example. She agitated and stimulated action from emerging clinical leaders of theNHS like Damian Roland and Stuart Sutton. She had the courage andhumility to appreciate that their ideas might be groundbreaking.Without her effort to provoke the conversation and the energy aroundit, NHS Change Day might not have been born. She viewed the entireworkforce of 1.7 million people as potential leaders of change, ratherthan those with positional power. She and her team of improvementleaders also provided cover to young leaders so they could be ‘enabled’to take Change Day forward.

This models the importance of allowing others to take the lead, and touse authority to protect innovative experiments like Change Day. As JoeMcCrea reflected, “There were certain very senior people without whom

Change Day would not have had its initial success. People like MilesAyling ‘got’ the idea and were prepared to back it and say ‘give it a go.’At the end of the day there was a huge investment in certain pledges. To have a huge presence at the centre of the Health Expo was alsoextraordinary.

“It was a big leap of faith from some very senior people. If this thing hadfallen on its face it would have left them feeling very embarrassed forhaving offered their support. That should not be underestimated.” In other words, senior leaders acted as signal generators to the NHSleadership community. Once they did so, many others started to pledgepersonally and to encourage their workforce to pledge.

These senior leaders accepted the reduced control that comes withgrassroots mobilisation. This does not always come easy to those inpositions of hierarchical authority, who are used to directing andcontrolling projects. The Change Day model demonstrated that givingpower away is what makes you powerful – together. Senior leaders canthereby help shape and inspire others.

One example of this comes from Flo Panel-Coates, Director of Nursing atBarking, Havering and Redbridge University Hospitals NHS Trust (seeAppendix A). “Every Thursday I have a clinical day. That involves mygoing into departments to talk to patients and staff, ask them abouttheir experience, what frustrates them. Some patients were very criticalof not having hot meals in the evenings. I have become a champion ofbringing hot meals back in wards for patients. It’s not just listening; it’sdoing something about what you hear. A colleague of mine, Jackie, hasled our work on this, but she needed some support. She is a Director of


Facilities, and I am a Director of Nursing, and it would have been hardfor Jackie to champion that change on her own, though she is aformidable lady.

She needed someone else to reflect the views of patients; it was easierto have someone to do it with together. We used NHS Change Day tospringboard pieces of work like this.”

This kind of modelling contributes to a shift in culture. Emma James, amember of the Communications Team at the Barking, Havering andRedbridge University Hospitals NHS Trust (see Appendix A), remarked,“I’m junior in the NHS, and I have found it to be very hierarchical. But Iwas most impressed with the executive leadership exercised aroundChange Day. We had some lovely directors who said ‘you are just asimportant as me.’ Having that feed through the organisation – ChangeDay helped us get the ball rolling to get a shift in culture – we are all in ittogether, it’s not just about those at the top. I want that to be feltthroughout the entire organisation.”

Flo agrees. “It is our job as an executive team to create the type ofenvironment that encourages people to do the right thing by ourpatients. We have to work to change the culture in the NHS. We tellpeople we want them to be innovative. We are constrained by doingthings the way we’ve always done them.” In other words, Change Dayhelped people step outside of daily habit and behaviours. “Our job is toget people to see things and do things different, and the freedom to dothat. We don’t have the ideas and solutions; that comes from our staff.We have to give them safety to act and not shoot down their ideas. Weoften hold people back; we want to keep people safe to make their ownmistakes and try things and fail and succeed!”

To support this kind of environment, senior leaders and managers have avital role to play in modelling the behaviours they hope others will take.When Jonathan Griffiths, a Member of Governing Body of Vale RoyalClinical Commissioning Group (see Appendix C), read NHS Change Daytweets and reviewed its website, its model of distributed leadershipappealed to him. He liked that anyone could commit to being a part ofsomething larger than themselves, connecting their local action to anational community with shared values. Jonathan committed tospending the day in a wheelchair in order to appreciate, promote andraise awareness about the experiences of wheelchair users andInternational Wheelchair Day.

Jonathan did not make a big deal of it, and he didn’t ask other people tojoin him or NHS Change Day. He believes in leading from example. “This is how I wish to lead. It’s not for other people. It’s what I believein; this is me being me.” Change Day afforded him the opportunity “toput himself out there a little bit.” These actions can trigger other things.Even if for some it is a morale boosting day, it is worth our spendingtime to figure out ways to better appreciate and enjoy the work we are doing.”

Some leaders have commented that Change Day could capitalise moreon the involvement of big names, big leaders in the NHS - but not as ameans of seeking permission. It wouldn’t be about ‘XX leader hasendorsed this,’ but more that senior leaders would be making pledges tothe effort, saying ‘this has to be done, and it doesn’t need to be down aformal route.’ Leaders and managers can explore the things that arehappening as a result of Change Day and talk about them, raise up goodexamples of innovation and patient care. Although coming from the‘bottom up,’ the ‘grasstops’ nonetheless carry some influence that cansupport the grassroots.


In turn, however, is a worry from the grassroots that the effort is beingco-opted or corrupted by senior leaders and managers. Even on the coreleadership team, there was disagreement about the involvement ofsenior leaders, stemming from concern that it could be confused andmisinterpreted. The authenticity of Change Day is about the ‘bottomup,’ and there was worry that ‘people at the grassroots will turn awayfrom the involvement of people at the top.’ The risk of perception ofsenior ‘stamps of approval’ was argued to be counterproductive to theauthenticity of the event.

Others argued that it was “both-and.” As Helen Bevan remarked, “TheNHS system needs to change massively. We need to educate our seniorleaders to develop a distributed leadership approach. It is great for themto learn to do things differently, for them to show that they can act fromtheir hearts as well as their heads. In every Call to Action we’ve engagedthe existing system and hierarchy as well as the grassroots. In ChangeDay 2013 some of the best activities were where whole organisationsgot engaged, like the hospital system in Bristol. What they saw was thattheir leaders were leading change in a different way. We will only have agreat NHS system in the future if the grassroots can engage and enablesenior leaders and managers to be a different kind of leader. ChangeDay offers that opportunity.”

This sentiment is shared at the highest levels of leadership. NHS Englandis working to increase and develop their citizen voice. Since Change Day,they invited Jackie Lynton to be part of the Design Team and HelenBevan to the Design Day to help them with their thinking. They said,“You’ve done it. What can we learn from Change Day?” Core teamleaders were invited to serve as facilitators to help the Department ofHealth with The Francis Report road shows to look at leadership andpromote positive practice in a different way. That is the kind of

leadership capacity being built from Change Day – not only at thegrassroots, but at the grasstops – and it is a transformative complementto hierarchy.

3.11 Outcomes: A ‘Dual Operating System’Along these lines, Change Day reflects a network-building approach thatJohn Kotter calls a ‘dual operating system’ – in which a hierarchicalstructure sits alongside a ‘network’ built on volunteerism, enthusiasmand commitment (Kotter, 2012: 6-8). This second ‘operating system’ isdevoted to the implementation of strategies that grow out of network-like structures.

These networks are able to assess and respond to rapidly-changing andcomplex constraints and opportunities with greater speed and creativitythan a traditional hierarchy, thus freeing both systems to do what theyare optimized to do. This second system accelerates strategic change.

Kotter suggests that there are five principles at the heart of this kind ofdual operating system (Kotter, 2012: 7):1. Many change agents, not just the usual few appointees2. A want-to and a get-to – not just have-to – mindset3. Head and heart, not just head4. Much more leadership, not just more management5. Two systems, one organisation

Change Day reflects all five of these principles in practice. It invites manypeople into strategic change-making. It asks people to commit becausethey want to, not because they have to – thereby building a volunteerarmy that is focused, committed and passionate. It draws on stories andexamples that appeal to people’s values and emotions, as opposed tosimply appealing to the logic of metrics and measurement. It asks


“everyone to be a leader,” encouraging all pledge-makers to contributetheir unique vision, opportunities, agility, action and celebration. It treatsits network and the hierarchy as inseparable, with a constant flow ofactivity between them – which functions because the volunteers in thenetwork all work within the hierarchy.

Although a typical hierarchy tends not to change from year to year, thenetwork “operating system” can adapt with ease. The second annualChange Day will look different than the first; the tenth annual will lookdifferent than the second. Pledge-makers will develop pledges to newconstraints and opportunities; improvements will build on improvementsand organisational change. The hierarchy can learn from Change Day, asits pledge-makers communicate where there is urgency to affect changewithin the organisation.

As Steve Fairman from NHS England (see Section 2.4) reflected, “I sit ina national job. My colleagues and I know the NHS has to changefundamentally in the next few years and offer a different type of service.What is the role of Change Day in that? We need to pay attention towhat people who pledge to Change Day are saying and doing. We needto link their small actions to the larger agenda around change in theNHS. They are communicating powerful messages about what wouldmake the NHS better.”

Steve continued, “To start with, the NHS more widely could learn a lotfrom how the leadership of Change Day happened – it showed that acompletely different type of leadership from the front lines can lead tosomething massive and important. It doesn’t need to have programmeplans and risk registers and business assurance reports. They are notwhat is critical. What is critical is people’s commitment. How you getthat commitment was modelled by those who led Change Day. I havenothing but admiration for those young people.”


Margery Shippen, volunteer at Leeds StJames’s Hospital, made this pledge: "I pledgeto smile at every patient I meet and greet…As a volunteer in the meet and greet service,

making patients feel at ease is my role."

CONCLUSION: LEADERS EVERYWHERE

One of the most significant lessons raised by NHS Change Day is aboutwhat it means to have “leaders everywhere.” NHS Change Day shows usthat it is possible to engage the grassroots, middle managers, and‘grasstops’ – each in particular ways – to contribute to the improvement ofthe National Health Service together. Both the anarchic and authentic spiritof “forget the rules – let’s just try it” and the collaborative and inclusiveattitude of “leaders everywhere” exist hand-in-hand in Change Day. But itis only through striking the delicate balance of frontline staff going for it,and senior leaders backing away from controlling it, that Change Day – andother efforts like it – will thrive.

Learning to strike this balance is an urgent priority not only for Change Day2014 and the NHS as a whole, but also for healthcare systems worldwide. Itreflects the tension that exists between the necessary role of hierarchy and itssignificant limitations. Hierarchy, and the bureaucracy that goes with it, can behighly effective at delivering standardised processes and pathways,incremental improvement based on ‘best practice’ or technical expertise and,at its best, reliably high performance based on effective management andaccountability systems. In situations where the challenges being addressed are‘simple’ (e.g. compliance activity) or ‘complicated’ (e.g. heart surgery)hierarchical decision-making can be not only necessary but the safest andmost effective structure. However, when the challenges being faced are‘complex’ – as is the case with most of the challenges currently facing theNHS – a reliance on hierarchical decision-making can be self-defeating(Snowden and Bone, 2007: 3-5). While excellent in many ways, traditionalNHS hierarchies can be too slow and too cumbersome to respond flexibly todifference, to the pace of change, to the appetite for innovation and changefrom both patients and frontline staff.

In practice an organisation like the NHS needs what John Kotter has called the‘dual operating system’ in which hierarchical structures sit alongside

‘networks’ based on volunteerism, enthusiasm and commitment. These networks give organisational form to the impetus for change that existsthroughout an organisation like the NHS, but which can so easily be stifled.The exercise of authority drawn from formal hierarchy (based on holding aparticular role or job title) or informal hierarchy (based on professional rivalries,gender, age) will undermine the shared purpose needed to make thesenetworks successful.

As John Kotter points out, creating a ‘dual operating system’ requiresconsiderable willingness to learn (Kotter, 2012: 12) – and in this regard NHSChange Day 2013 offers a significant opportunity. Drawing on socialmovement theory and the practice of community organising, NHS ChangeDay deploys skills, behaviours and structures which – if amplified further – cangive life to motivated networks capable of taking action across the NHS.


Skills• Developing the capacity to use narrative as a tool for motivating othersto join you in action.

• Developing relational skills to enable the continual recruitment of newvolunteers and the deepening of commitment of those already recruited.

Behaviours• Developing a shared purpose based on shared values to provide themotivating vision for a team.

• Practising interdependence based on clear roles, mutual accountabilityand intentionally strengthened relationships within a team.

Structures• Distributed leadership structures based on interdependence andaccountability rather than hierarchy.

• Enabling strategy to be developed at multiple points within the systemrather than driven from the top or centre.

There is no question that some will find it challenging and perhapsthreatening to operate both interdependently within a network andhierarchically within a formal organisational structure; this way of workingis certainly not for everyone. However, failure to embrace the value andpossibility of networks of this kind will do nothing to reduce thechallenges facing the NHS and could do a great deal to make them worse.As NHS Change Day has shown, enabling both operating systems toflourish requires the active participation of leaders at all points – from thegrasstops to the grassroots.

An effort like Change Day resulted in traditional evidence-based impactsacross all pledges, but its design builds commitment, relationships,motivation, leadership and – ultimately – power to achieve better patientoutcomes throughout the NHS. As a whole, Change Day empowers actionby cultivating a safe and celebratory space for people to step outside oftheir everyday lenses, habits and behaviours to look at somethingdifferently, to appreciate a patient or colleague with greater empathy, orto try something in a new way. It galvanises people to focus on goodwilland taking action, and it creates urgency to do it. It is fun. And it allowspeople to feel a part of something bigger than themselves, to see thattogether their actions can assert influence over the system as a whole.

To that end, it is important that the leadership framed the Change Day callto action and its underpinning narrative as about commitment, notcompliance. In speaking with pledge-makers, we also discovered that themore relational the pledge, the more profound the experience for thepledge-maker – both in terms of immediate and ongoing impact. Yet thelevel of commitment is for a pledge-maker to decide; and the high degreeof personal decision-making over the nature of a specific voluntary actionis what enabled so many people to participate in the first place. This created the necessary conditions for hundreds of thousands ofindividuals to step forward and exercise leadership by making a pledge,and in many cases mobilizing others to do the same.

Beyond all this, what final lesson might similar efforts learn from NHSChange Day? Simply put, social movement theory can be applied in manydifferent health care settings. Look no further than the breadth of pledges,geographies, types of individuals and organisations that took part in NHSChange Day 2013 for national and local models of distributed leadership.We are grateful for all that they teach us, and we encourage us all to be apart of Change Day 2014 – in England and around the world.


Nas Kadeem, Adult Safe Guarding Leader at Tameside Hospital,made this pledge: " I pledge to smile a 50 people within my work

place on NHS Change Day."

RECOMMENDATIONS

Engaging with existing NHS processes: NHS Change Day wassuccessful in part because it engaged with – but was not owned by – thehierarchy. There is a likelihood that the success of Change Day 2013 willattract the support of senior leaders keen to be associated with ChangeDay 2014. While this support may bring resources, it may also bring theconstraints that come with being part of any formal hierarchy and therebyundermine the voluntary and networked relationships that were at theheart of Change Day 2013. For these reasons we recommend that NHSChange Day 2014 remain outside the formal NHS communication,improvement, training and management structures. This means signing upfor ongoing tension and uncertainty, as well as the commitment andenthusiasm that volunteerism brings.

Senior Leaders: Senior leaders have a critical role to play in the success ofNHS Change Day 2014, most especially by acting as role models. We strongly encourage them to pledge, to choose something that reflectstheir values, and to find ways of sharing this story with others. Werecommend that senior leaders resist the temptation to manage ChangeDay 2014 or mandate participation, and instead take the opportunity tomodel the value of enabling others to lead, using their positional authorityto hold up the successes and stories of pledge-makers – and todemonstrate how senior leaders are learning from them.

Structure: In one sense NHS Change Day 2013 was highly centralised; itrelied heavily on the leadership of a core team. This created significantpressures on a small group of people, reduced the potential strategiccapacity of the core team and limited the ability to provide on-the-groundsupport and training to pledge-makers. We recommend that Change Day2014 develops a more intentional structure of distributed leadership thatallows teams throughout the country to take responsibility for particularaspects of the overall strategy.

These teams could be based on geography, professional groups, particularpledges or necessary functions (e.g. technical support). Their roles should be clearly defined, and the core team should in part bedrawn from them. We recommend that the teams that make up theleadership of NHS Change Day 2014 are structured interdependently.

Skills and capacity: By participating in NHS Change Day 2013, many peoplein the NHS developed new skills – in narrative, building relationships,campaign management, social media, communications, and beyond. Werecommend that planning for NHS Change Day 2014 includes creatingopportunities for them to be passed on to others through trainings, webinars,online skills sharing, printed and online resources, and more.

Emerging leaders: As with many social movements, NHS Change Day2013 drew much of its initial impetus from the passion and commitmentof grassroots staff. Younger members of staff may have fewerpreconceptions about how things have traditionally been done and maybe less invested in existing hierarchical structures – making themparticularly attracted to a ‘networked’ way of working. They may also bemore naturally familiar with social media. While NHS Change Day as awhole should seek to mobilise across generations, we recommend that thegrowth strategy for NHS Change Day 2014 includes a focus onidentifying, recruiting and training emerging leaders from all parts of theNHS and beyond.

Patients, their families and citizens: NHS Change Day 2013 wassparked by NHS employees, and pledge-makers were overwhelminglydrawn from NHS staff. Building on this success, we recommend that theNHS Change Day 2014 strategy targets ways for patients, their familiesand citizens in general to contribute to the overall effort. Theirinvolvement would amplify the values that underpin the NHS, and which


are shared by the public. It would also help to blur the boundariesbetween ‘patient’ and ‘staff,’ reinforcing the sense that the ‘NHS belongsto us all’ and that ‘we share responsibility’ for improving and safeguardingit. Along those lines, NHS staff can be encouraged to recruit familymembers (children, parents) to make pledges. To ensure patientengagement, patients should also participate in the core leadership team.

Integrate online and offline strategies: Much of NHS Change Day2013’s success was the result of online activity, especially Twitter and theonline pledge wall, as well as alerts that enabled a community to developamongst pledge-makers and their supporters. Change Day action, ofcourse, takes place off-line. There is now considerable experience amongstcampaigning organisations of how best to integrate online and offlinestrategies. This is often described as a three-step process that is constantlyrepeated during the life of a campaign:

1. Engage people online: secure commitments/pledges, provide onlineresources, enable supporters to build community with others.

2. Take action offline: recruit others, follow through on pledges, recordusing video/photos.

3. Bring people back online: track progress, gather data and feedback,post video/photos, share stories and make the nextcommitment/pledge.

This process could assist not only with securing action during Change Day itself but also building support in the run-up to Change Day. We therefore recommend that NHS Change Day 2014 includes anonline/offline strategy that continues draws inspiration from contemporarycampaigns and social movements.

Build on successes: There were a number of pledge-makers who wereparticularly successful at mobilising others, often within a specificorganisation (e.g. Birmingham Children’s Hospital; Barking, Havering andRedbridge University Hospitals NHS Trust; and Derbyshire CommunityHealth Care Trust). Many of these have the capacity to grow considerablyin future. We recommend that NHS Change Day 2014 intentionally seekto build on these notable successes by providing support to the teams ofleaders on the ground.

Campaign approach: An annual campaign to hit a target number ofpledges on a particular day each year is central to the Change Day design.The core leadership team, as well as local pledge-makers, can ‘chunk out’this target over a longer period of time, kicking off the Change Day effortearlier in the year and developing tactics to achieve smaller pledge-targetsalong the way.

We also recommend the development of a long-term strategy for ChangeDay. What should “Change Day” mean to people in ten years? To whom?To how many people in England? To how many people around the world?The team can then work backward to develop a long-term strategy thatleaves room to incorporate new thinking and leadership each year.Emerging constraints, opportunities and learning will guide it over time.

Goals and metrics: Mobilising people to take action will remain thecentral goal of NHS Change Day. We recommend that Change Dayleadership set an even more ambitious target for the number of pledgessecured in 2014.


To develop impact measures, the Change Day core team can ask pledge-makers to report on their actions and outcome metrics on the onlineplatform. They can also invite pledge-makers to commit their pledge foronline “tracking” of learning and metrics after 3-, 6-, 9-, or 12-months.

In addition, we recommend that the Change Day leadership team identifya small number of metrics that demonstrate the impact of pledging onpatients and staff. These could include: impact on staff morale; number ofpledges that involve “intentionally experiencing an aspect of the NHSthrough the eyes of another staff or patient”; or the impact of pledgesfocused on positivity on staff performance and patient care.

Beyond impact measures, developing metrics around the NHS Change Daydesign elements is possible and desirable. How many people told anonline or on-the-ground narrative to mobilise others to join their pledge?How many new relationships were built through Change Day? Has thepledge led to other voluntary or collective actions? How many peoplewere inspired to join a particular pledge? Quantifying the design elementsof the Change Day approach will help tell the story of how it is enablingdistributed leadership, voluntary commitment, and new relationships tolead to innovation and improvement in patient care – and contribute toother organisational change efforts long after Change Day.

Opportunities for research: Certain 2013 pledges took off like wildfire.For instance, over 3500 pledge-makers committed to smile at someone

else (like patients or colleagues). At face value, one might assume thatlittle impact could come from the act of smiling on one particular day. But there is a growing body of research around the effects of positivity,including smiling, on health and wellness – not only in terms of the impacton the person who is smiled at, but the person who is smiling! It boosts

morale, leads to feelings of empathy, builds relational resources, broadensawareness, develops trust, and leads to better negotiations, better medicaldecisions, more creativity, more resilience, better memory for details,improved ability to focus, and improved perspective (Fredrickson, 2013:60-69; Fredrickson and Branigan, 2005: 313-332; Schmitz, De Rosa andAnderson, 2009: 7199-7207; Rowe, Hirsch and Anderson, 2006: 383-388; Isen, Rosenzweig and Young, 1991: 221-227; Waugh andFredrickson, 2006: 93-106; Dunn and Schweitzer, 2005: 736-748;Kopelman, Rosette and Thompson, 2006: 81-101). This is an example ofthe endless possibilities for research partnerships with pledge-makersinvolved in Change Day, particularly around demonstrating impact. We encourage Change Day leadership, pledge-makers and researchers toinvite and pursue these opportunities.

Global movement: The NHS has sparked a movement that has gone global.Change Day 2013 included pledges from people the world over. Emergingclinicians and leaders from other healthcare organisations in Norway, Canada,Australia, Denmark, the United States, and beyond are keen to participate inChange Day 2014 – and lead local efforts to mobilise those in their owncountries and organisations. Although initiated and branded by the NHS inEngland, all of us share the opportunity to embrace distributed leadership andvoluntary collective action toward patient care and quality improvements. We recommend that the NHS continue its work to support global leaderslearning from its approach, and to invite others to join them in a worldwide“Change Day” with no one particular organisational affiliation, but the sameapproach and objectives.To do so, we recommend virtually convening an internationally-diversegroup of frontline clinicians, patients and improvement leaders to developa global “Change Day” governance structure and online coordinatingplatform. The global platform could seamlessly allow for pledge-countsfrom each participating organisation or nation to contribute to a global


count of pledges, while featuring various pledges to develop a globalcommunity. In addition, the online platform can be designed to allow fordata-sharing and produce co-learning opportunities between countriesand organisations. Finally, a global pledge could be highlighted as onepossibility to pledge-makers everywhere as a way in which to harnessworldwide collective action.

Along these lines, we recommend that improvement leaders outside theNHS in England commit to at least two design elements of Change Day.First, follow the central premise of the Change Day approach: recruitleaders on the ground to lead the effort. It is important that Change Dayleaders – everywhere – embrace the approach of distributed grassrootsleadership and voluntary commitment, in contrast to senior leadersbringing Change Day to groups through top-down compliance models.Second, determine with frontline leaders what expression of Change Daymakes sense within local contexts and constituencies.

Already Change Day 2014 is a date that many healthcare leaders in theUK and around the world have put in their calendar: 3 March 2014.

This is testament to the extraordinary leadership shown by a dedicatedgroup of people in the NHS in England who imagined a mass movementof people taking action together to improve healthcare. More than that, itdemonstrates that new models of distributed leadership can developalongside traditional hierarchies; and that when “leaders everywhere” aremobilised, great things are possible.


Core leadership team 2013

REFERENCES

Alexander, Ruth (2012), “Which is the World’s Biggest Employer?” BBCNews Magazine at http://www.bbc.co.uk/news/magazine-17429786

Bate, P., Bevan, H. and Robert, G. (2006), Towards a million changeagents. A review of the social movement literature: Implications for largescale change in the NHS, NHS Modernisation Agency athttp://discovery.ucl.ac.uk/1133/1/million.pdf

Bennett, Nigel, Wise, Christine, Woods, Philip A and Harvey, Janet A(2003). Distributed Leadership: A Review of Literature. National Collegefor School Leadership at http://oro.open.ac.uk/8534/1/

Dunn and Schweitzer (2005), Journal of Personality and Social Psychology,88, 736-748.

Fredrickson, Barbara L. (2013) “Increase Your Daily Diet of Positivity: Why& How,” Coaching in Leadership & Healthcare, The Institute of Coachingat McLean Hospital, pp. 60-69.

Fredrickson & Branigan (2005) Cognition & Emotion, 19, 313-332.

Granovetter, Mark S., “The Strength of Weak Ties,” American Journal ofSociology, Vol. 78, (May 1973), pp. 1360-1389.

Ganz M (2010) Leading Change: Leadership, Organization, and SocialMovements in Handbook of Leadership Theory and Practice, Nohria N andKhurana R (eds), Chapter 19, HBS Press

Ganz, M. (2010) “Leading change: leadership, organization and socialmovements,” in Nohria, N. and Khurana, R. (ed.) Handbook of LeadershipTheory and Practice, Cambridge: Harvard Business School Publishing

Isen, Rosenzweig and Young (1991), Medical Decision Making, 11, 221-227.Johnson and Fredrickson (2005), Psychological Science, 16, 875-881.

Katwala, Sunder (2011), “NHS Makes Socialists of Us All, Says Tory MP,”Next Left: A Fabian Society Blog at http://www.nextleft.org/2011/04/nhs-makes-socialists-of-us-all-says.html

Katwala, Sunder (2013), “The NHS: Even More Cherished than theMonarchy and the Army,” New Statesman athttp://www.newstatesman.com/politics/2013/01/nhs-even-more-cherished-monarchy-and-army

Kopelman, Rosette and Thompson (2006), Organizational Behavior andHuman Decision Making, 99, 81-101.

Kotter, John P. (2012) “Accelerate: How the most innovative companiescapitalize on rapid-fire strategic challenges – and still make theirnumbers,” Harvard Business Review, November

Lynton and McCrea (2013), The difference a day makes….Interim Reportfor NHS Change Day 2013, atwww.changemodel.nhs.uk/dl/cv_content/64646_


NHS Improving Quality (2013), “Biggest ever day of collective action toimprove healthcare that started with a tweet” athttp://www.mixprize.org/story/biggest-ever-day-collective-action-improve-healthcare-started-tweet-0

NHS Institute for Innovation and Improvement (2011), “The RightPrescription: a call to action on the use of antipsychotic drugs for peoplewith dementia” athttp://www.institute.nhs.uk/qipp/calls_to_action/Dementia_and_antipsychotic_drugs.html

Northouse, Peter G (2013) Leadership. Theory and Practice, 6th ed.London: Sage

Rowe, Hirsch and Anderson (2006), Proceedings of the National Academyof Sciences, 104, 383-388.

Schmitz, De Rosa and Anderson (2009), Journal of Neuroscience, 29,7199-7207.

Snowden, David J. and Bone Mary E. (2007) “A Leader’s Framework forDecision Making,” Harvard Business Review, November

Talarico, Berntsen and Rubin (2009), Cognition & Emotion, 23, 380-398.

Waugh and Fredrickson (2006), Journal of Positive Psychology, 1, 93-106.


APPENDICES

Appendix A: The Story of Barking, Havering and RedbridgeUniversity Hospitals NHS Trust

Who: Flo Panel Coates (Director of Nursing), Emma James(Communications Team Associate) & Ashley Brooks (National PatientChampion)

Where: Barking, Havering and Redbridge University Hospitals NHS Trust

When, pledged for how long: On Change Day and beyond

What (Pledges) & Why: Flo Panel-Coates: Flo pledged that she wouldlisten to more patients and staff. “For me it was about something I wasalready committed to doing, but I was being clearer to others about what Iwas doing and why. It allowed me to informally ask people’s views andopinions, and I have continued with that.”

Emma James: Emma pledged to be a change agent. “I looked for ways tomake change, and if I found those resistant to change, I committed towork with them to find another way… I never want to stand still as aperson or organisation; we should always be looking to change ourselvesand others to benefit the patient.”

Ashley Brooks: Ashley pledged to protect the NHS. “I want to protect theNHS because I want it here for my children. At the moment, I am workingto protect nursing staff. They are the first to get admonished for anyproblem on the front line.” As one part of protecting the NHS, Ashleypledged to say thank you to staff as often as possible. “Our staff aren’tthanked enough. I say thank you for saving my life, for saving my father.

Just saying thanks helps reconnect us to why we came to our work: becausewe care about and love patients. Saying it out loud makes it real.”

How they got involved: Flo and Emma first heard about Change Daythrough a director at the Trust who made a pledge and supported ChangeDay locally and nationally. As Emma stated, “When Donna (director) firstheard about Change Day, she asked me to help staff learn what it wasabout, how to get involved. I was responsible for the educational processat the Trust. We have regular staff meetings each month, and we startedoff gently telling people it was coming up, what it was, what you coulddo. Then we built it as a campaign. We had posters everywhere. Each week we did features on who was making pledges, and what theywere. We focused on a range of staff members from a midwife to theChairman of the Trust. Our aim was to make sure everyone in ourorganisation (6,000 people) knew about Change Day and to entice themto get involved and make a pledge.”

Ashley learned about Change Day from national Change Day teammember, Jackie Lynton. He saw himself as a “conduit” between thenational team and the Barking, Havering and Redbridge UniversityHospitals NHS Trust. In light of some negative press around theorganisation at the time, Ashley saw Change Day as a chance to dosomething positive. He encouraged others to participate in Change Day bysending emails to his colleagues, and at first, no one responded to him.“People had huge pressure to deliver on things that were much biggerthan Change Day. Understandably, we often look after the problems thatare most urgent first. But in late November, I said if no one does this, I willgive up on it! Then everyone wanted to make it happen and got togetherto move it forward.” This story illustrates the power of offering people achoice in the face of a challenge, particularly those that we sharerelationships with.


Why they got involved: The urgent ‘moment’ surrounding Change Daywas one motivating factor. As Flo stated, “On the one hand, we wereresponding to the Francis inquiry. The NHS was in trouble, and werecognized the need to do something differently. NHS Change Dayprovided that opportunity by focusing on contributions that individualscould make, instead of focusing on the problems that we face. Our director made a positive pledge to take action to encourage theopenness and candidness of staff.”

Change Day also provided an opportunity to experiment. “We chose touse NHS Change Day to try different things, to experiment. There is bigstuff we need to do and we know that; but what we wanted to telleveryone was that each of us can bring something to the table; we don’tneed to wait for someone to tell us. It’s about the little things we can dostraight-away” (Flo Panel-Coates).

Emma added, “Change Day empowered people to act. It allowed our staffto come up with their own pledge, declare it online, and do it withoutanyone else creating a barrier. It gave people a place to grow their goodideas. It also empowered the organisation to see where we could makelarge or small scale improvements by listening to people on the ground.”

How the pledge worked: Flo’s pledge: Flo offered numerous examplesof how she listened to more patients and staff – and then did somethingabout what she heard. “Every Thursday I have a clinical day. That involvesmy going into departments to talk to patients and staff, ask them abouttheir experience, what frustrates them. Some patients were very critical ofnot having hot meals in the evenings. I have become a champion ofbringing hot meals back into wards for patients. A colleague of mine,Jackie, is a Director of Facilities, and she needed some support on this

issue. Although she is a formidable lady, it would have been hard forJackie to champion this change on her own; she needed someone elsewho could reflect the view of the patients. I am the Director of Nursing,and I could help. We used NHS Change Day to springboard pieces ofwork like this – together.”

Emma’s pledge: Emma worked with Ashley to develop a campaignapproach to engaging other staff in Change Day. “Because it was a day,we built up to that day, and localized our campaign to our staff. We had alittle whiteboard where people wrote their pledges in large print, and wetook pictures of them holding them so we could post this visualcommitment. It made it personal and specific to our hospital staff.”

Emma publicised Change Day among matrons at their monthly meeting,in Staff Briefings (which in theory should have trickled into TeamBriefings), through stories on the intranet, in the weekly staff newspaper,via desktop images on staff computers. She also visited wards to raiseawareness of the campaign and spoke to staff on Change Day.

She also enabled staff to submit pledges easily. Staff could make pledgesby visiting the Change Day website, downloading a form and sending itback to the communications office or handing it in at the maininformation desks, using the electronic pledge form on the intranet, ortweeting their pledge to #feedback.

“Forty-three people made pledges. At the beginning people pledged tosmile more or say thank you; then bolder and bigger pledges emerged aswe got closer to Change Day. It made people stop and think what theydidn’t like and the role they could play in bringing about positive changesfor staff, patients or the organisation as a whole. There were a few team


pledges; and they may have been spearheaded by individual staff but by thetime I met the teams everyone was enthusiastic about the pledge andwanted to play their part, too. The individual pledges were brilliant too.One top consultant committed to sitting in the waiting room to experiencewhat our patients see and feel. We’ve followed him through the year to seehow it is working, how it is going for him, and shared it with other staff.”

“We wanted it to be about that day; and every year we are doing to do it.We have gone back to people who made pledges and asked them how itwent and run articles on it in the staff newsletter. We will keep it runningin the background until we start the build-up for Change Day 2014.”

Ashley’s pledge: “One of the commitments that we made was tointroduce something called the ‘Patient Champion.’ Prior to Change Day,we learned that when staff witness something or have concerns, they areafraid to raise them with manager or peers. Even though we have awhistle blowing policy, not one person has ever used it. I play a nationalrole and am independent of the organisation; so I have become thepatient champion. There is no fear of retribution or harm to reputation byraising concerns with me. Since June 27th, over ten people havecontacted me to raise their concerns about other staff or practices. This isa very important change.”

Flo added, “Ashley has helped us deal with the issues confidentially andfed back to staff what we’ve done as a result of what they’ve brought tohim. The fact that we’ve had 10 people come forward demonstrates itsvalue. They feel they are being listened to and are taking their concernseriously. Even if we can’t resolve it right away, we’re trying to makethings better. And they won’t receive any backlash from management forthe issues they’ve raised.”

Lessons:Emma conducted an internal evaluation of what worked well and howthey could improve in engaging more staff in Change Day. She submittedsome of the following findings:

What worked well: • Publicising the event:Most people had heard of Change Day by the 13th ofMarch.

• Staff pledge photos: Staff liked seeing the photos of other colleagues’pledges in their departments.

• Conversations at NHS Change Day stall & visiting staff in their departmentsand wards: On Change Day Emma and Ashley spoke to people about theirjobs and what they did by asking: “How long have you worked here, whydid you come to work here, what do you like, what would you change?”Staff opened up. By having a conversation, rather than just asking whetherpeople had made a pledge, staff felt listened to and where more likely tomake a pledge then and there.

• Learning from staff: As Emma James reports, “Change Day gave staff therespect they deserve, by taking time to ask them, ‘What can we do, whatcan we be?’ There has been a tendency in the past to not listen to staff[because] you may hear things that you don’t want to. There was adifferent atmosphere around Change Day. The executives wanted to hearwhat staff thought, and they wanted those messages loud and clear. Those messages will help us transform the organisation to be a better placeto work and for us to deliver a better service for patients.”

• Senior staff backing: Senior figures supported the event, which signalled tostaff that there was not a barrier to participate.

• National NHS Change Day visit from Jackie Lynton: Jackie visited wards anddepartments, inspiring staff to take part in Change Day – which wasevident from the numbers of pledges received from staff in the wards thatshe visited and their enthusiasm for Change Day even after making theirpledges


What can be improved:• Signals from senior leadership: Some senior leaders projected a feelingthat the Trust had been under scrutiny and underperforming soeveryone should already be working on ways to improve our services.They also dismissed simple pledges such as “keeping my patients moreinformed of delays in treatment or appointments” as things that staffshould do anyway. It would have helped if they had led by example andmade pledges.

• Ownership by staff: Many still saw the effort as a top-down initiativethat people were being ‘forced’ to take part in, rather than it being ledby them. We need to engage more frontline staff in leading the effort;and we need to ask senior leaders to play a supporting role.

• Confusion about pledges: There was confusion about what pledgeswere or who they were for. Some members made suggestions aboutthings that the Trust should be doing, rather than making individualpledges. Nonetheless, these suggestions are being followed up on!

• Being prepared to handle concerns that are raised: Cultural andinterpersonal issues surfaced through Change Day. Four staff reportedteam members that were causing problems for the rest of the staff,being rude or underperforming. Being prepared to address thesesituations is important as we encourage people to identify areas forimprovement and change!

Recommendations:• Support pledge-makers by following up with them to see if they hadfun, learned anything, or made progress of some kind. Encouragelonger-lasting effects of pledges.

• Debrief staff for any key issues, lessons or concerns that were raisedthrough Change Day.

• Visit more wards to talk to staff face-to-face about what they careabout, what motivates them to do their jobs, and how to improvepatient care.

• Be clearer about what a pledge is and is not.• Get senior staff backing, but invite frontline staff to lead it.• Work with unions at a national level and with staff side representativesat the Trust to get their backing and spread the word

Ideas for involving the public:• Outreach: Teams made up of GPs, matrons, staff visit local churches,schools, mosques, etc., and explain what Change Day is and invite themto get involved.

• Use Change Day to create awareness about how to access care: Forexample, our Emergency Departments are so busy, we can engage thepublic in learning more about walk-in centres, how pharmacists canprovide advice for colds and coughs, etc. through Change Day.

• Change Day could be a recruitment drive to get young people toconsider a job in the NHS:We can show the diversity of roles frombackroom staff to chefs, in addition to clinicians.

• Building relationships with staff and public: Many people felt that recentchanges to the NHS (i.e. the biggest reorganisation in 63 years) wereundertaken without a mandate. During NHS Change Day 2013 we sawthe Government trying to repair some of this damage by praising all thehard work and dedication of those who work in the health service. ForChange Day 2014 staff can reach out to other staff and the public andask them how to improve their experience of delivering or receivingcare. Staff and patients should support changes to their health service.

• Celebrities, sports personalities and those who have been helped by theNHS: Ask them to serve as representatives of the public face of the


campaign to engage the public. They can champion NHS Change Dayon morning and evening news shows (e.g. BBC Breakfast, The OneShow). We could even ask the Royal Family and key public figures suchas the Prime Minister and London Mayor whether they would visitTrusts, GP Surgeries and other NHS Facilities to say “thank you” to staff.

• Work with TV channels to air health related documentaries and dramas:For example, the BBC could air special episodes of Holby City orCasualty, or re-run old programmes such as Carry on Matron.

• Branding for kids: There could be a Change Day mascot for children tohave their photographs taken, stickers, balloons – more fun!

• Double-decker Change Day bus: It could travel to city centres to pitchChange Day as a road show with both national figures and localleaders.

Changes in thinking and leading: Change Day helped amplify ideasand accelerate actions already percolating among staff. As Ashley related,“Change Day gave people permission to be creative and innovative andnot be frightened to make commitments to improvement. That permission gave people room to take action to safeguard patients. It accelerated conversations to a higher level. Guardian Services is oneexample. Potentially Guardian Services would not have been discussed;Change Day was a great motivator for creative ideas! It helped toaccelerate and amplify good work.”

Flo related that it is the job of executive leadership to support efforts likeChange Day. “It is our job as an executive team to create the type ofenvironment that encourages people to do the right thing by our patients.We have to work to change the culture in the NHS. We tell people wewant them to be innovative. We are constrained by doing things the waywe’ve always done them.” In other words, Change Day helped people

step outside of daily habit and behaviours. “Our job is to get people to seethings and do things different, and the freedom to do that. We don’t havethe ideas and solutions; that comes from our staff. We have to give themsafety to act and not shoot down their ideas. We often hold people back;we want to keep people safe to make their own mistakes and try thingsand fail and succeed!”

She added: “Most executive teams are not this way; but they want to be.We get caught up in our day jobs and we miss the point about culture andthe environment and the impact on others in our organisations. We don’tmake things easy for people; we are battling a system that isn’t alwaysready for it.”

NHS Change Day approach: This kind of modelling contributes to a shiftin culture. Emma James, a junior member of the Communications Team,remarked, “I’m junior in the NHS, and I have found it to be veryhierarchical. But I was most impressed with the executive leadershipexercised around Change Day. We had some lovely directors who said ‘youare just as important as me.’ Having that feed through the organisation –Change Day helped us get the ball rolling to get a shift in culture – we areall in it together, it’s not just about those at the top. I want that to be feltthroughout the entire organisation.”

Ashley recognized that Change Day builds on other improvement effortsbuilt on social movement design elements. “Change Day for me is thenatural progression of the organizing work from the Calls to Action… It ishow you present a call to action, making it as simple and effective andemotional as possible so people commit. A call to action requires everyoneto take action; and if we do, we can’t fail. Most people get it – if we all dosomething together, if we do it as a large group, we can get something


done. It’s not top-down and it’s not bottom up; it’s people comingtogether – like a church – to get something done. Let’s change things,let’s ask whether we are including others, let’s ask whether we are doingwhat we know is right. And it all starts with a pledge.”

As a younger leader, Emma noted that it felt like an effort led by thethinking of Generation Y. “The whole approach is very modern. It isgrassroots, people tweeted, used social media – it is not something thatwe’ve done before. It was like borrowing ideas from political campaigns,and using modern elements that show we are the next generation – andwe are taking ownership in the NHS.”

Ashley reflected on ways to improve the Change Day approach in futureyears. “Change Day 2013 focused on employees and staff of the NHS. It should be a lot bigger. It should include patients – there are millions ofpatients who love the NHS. Let’s focus on the public and patients. If wego back to World War II, one of the biggest marks of success for thewarwas: ‘What can you do for your country?’ We need to ask: ‘What canyou do for your NHS?’ Change Day has a huge energy behind it; and wehave to widen its scope.”


Appendix B: The Story of Birmingham Children’s Hospital

Who: Janette Vyse, Lead for Patient Experience & Participation; EllieMilner, Patient Experience & Participation Support Officer; Harriet Giles,Health Promotion Support Worker; Jane Powel, Lead for Health Promotion

What: At Birmingham Children’s Hospital, we pledge to go that extra mileand make someone smile!

Where: Birmingham Children’s Hospital

When, pledged for how long: NHS Change Day itself (with someongoing actions)

How Birmingham Children’s Hospital got involved: The PatientExperience & Participation Team at Birmingham Children’s Hospitaldescribe their approach as focusing on “developing a culture of workingin partnership with children, young people and families.” “It’s aboutpatient communication and how that impacts on patient outcomes andexperience,” says team leader Janette Vyse. “That’s what underpins ourenthusiasm.” So it was only natural that team member Ellie Milner, whohad herself been a patient representative at Birmingham Children’sHospital, responded so enthusiastically when she first heard about NHSChange Day. The rest of the team were equally positive seeing ChangeDay as a “fantastic opportunity to have an impact.” Having looked at theChange Day pledge wall, the Patient Experience & Participation teamknew the project would benefit from support from the Executive Teamand approached Chief Nurse Michelle McLoughlin, Executive lead forPatient Experience & Participation, who was equally supportive and agreed

to put the pledge up in her name which the team felt “helped to define itas a hospital-wide pledge.”

Why Birmingham Children’s Hospital got involved: “We thought thatChange Day would be another way to get the message out about theimportance of patient experience and the idea that little things can makea big difference. This was one day when we could do lots of little thingsthat could make a big impact.”

Why this pledge: The Patient Experience team decided early on that theywanted to involve as many people across Birmingham Children’s Hospitalas possible on NHS Change Day – a local version of the nationalmobilisation. They were also keen to come up with a pledge that wouldnot exclude non-clinical staff – so enabling staff to take action to supportother staff as well as patients was an important early consideration. “We sat down as a team and discussed the options,” say Janette Vyse.“We didn’t have huge amounts of time so there was a real sense ofurgency.” Initially the team considered asking staff to make their ownindividual pledges but they felt that this would make it harder to get thewhole hospital to take part.

It was during a brainstorming session that the “go the extra mile to makesomeone smile” idea surfaced. It appealed partly because it was simpleand gave individuals the opportunity to come up with an action that wassuitable for their own part of the hospital. It also reflected the evidenceshowing that it does indeed matter to patients that staff smile. For stafffacing multiple pressures, it was also appealing to be able to offer a smileto each other, suggesting that “it’s ok to say that we do things well.”


How the pledge worked: The BCH strategy for Change Day had twoelements. First, the Patient Experience & Participation team planned anumber of activities that would bring a smile to patients. “The idea was tocome up with something that would make a child or young person smile,”says Janette Vyse. With the backing of the Chief Nurse they secured a smallamount of money to pay for face painters, a balloon modeller, a magicianand, for the older children, a beautician to spend the day in the hospital.The team coordinated the activities moving the various entertainers fromone part of the hospital to another and from ward to ward.

The second part of the strategy was to recruit other staff from across thehospital to come up with their own actions and to provide them with anysupport and encouragement they needed. Emails were sent to Heads ofNursing and Ward Managers but, more importantly, Ellie Milner and HarryGiles were regularly in and out of the wards as part of their day job andwere well known by the clinical staff. Janette Vyse explains, “When theywere doing their ward visits, they would talk to the ward manager aboutChange Day and provided lots of posters and the pledge slips! Both Ellieand Harry’s natural enthusiasm really helped to ‘sell’ the day!”

These face-to-face visits were crucial to securing support across thehospital as was the fact that the pledge that staff were being asked tomake was entirely voluntary and doable: “We weren’t asking people to dosomething that was a big additional workload.” The team was able toshare examples of pledges that were being made in other parts of thehospital and to offer to help if needed on Change Day itself.

Outcomes: As a result of all the work that had gone into their pledge, 13March 2013 was very special at BCH: “The day had a lovely feel – peoplesmiled! And people commented on that continually. What made it such a

success was that people participated. We saw it visibly happening – seeingsmiles on the faces of the patients and how staff had embraced it.”

The positive effect spread to everyone involved: “People who participatedgot a sense of wellbeing – if you give, you get. There was a real sense ofcaring for each other as staff, of camaraderie, or doing somethingtogether.”

Many of the specific pledges were made by wards and units:• The staff in one ward laid on breakfast for parents who had to stayovernight in hospital with their children while in another ward theybrought in cakes and in a third provided additional art and craftactivities.

• The Outpatients staff teamed up with the volunteers who ran the ArtCart to make a wall covered in paper-plate smiles.

• The Burns Unit gave out bravery certificates and stickers after dressingswere changed.

Other pledges and actions were individual and could be very simple: “Weknow of one person who phoned a colleague in another department justto thank them for the work they do.”

The Clinical Photography unit pledged to ask for feedback from eachperson that they came into contact with during the day. A little nervous atfirst, they found that it was in fact a very positive experience with anumber of ongoing benefits. First, they became more skilled at havingeffective feedback conversations. Second, they found that they receivedmuch more relevant and valuable feedback than they usually received ontheir standard feedback from. Finally, they identified this approach toreceiving feedback as being much more effective for a service that forms


only a small part of the patient journey (most patient feedback typicallyreferring to ward-based activity). This experience has been so positive thatthe Clinical Photography unit has instituted regular ‘feedbackWednesdays’ which have also been taken up by in-patient Pharmacy, andthe CAMHS team.

Lessons: It was a very different experience asking people to volunteer onthe basis of commitment rather than trying to get them to agree becausethey were being required to participate: “We were honestly able to say‘we would love you to!’”

The reason that people participated was because the pledge was relevantand personal: “People instinctively knew that it would make a differenceto patients.

“The approach felt naturally values-based and caring which seemsappropriate for the work of BCH.“It reinforced what we already know – that it is possible for little things tomake a big difference.”

Changes in thinking: “Putting in the effort to make someone smile doeshave an impact – on the staff who are ‘going the extra mile’ as well as thepatients. It helps to keep patient care at the forefront of our mind.

“We will approach next Change Day with a greater sense of certainty thatwe will be able to make a difference – because we already have made adifference.”

Changes in leading: For the Patient Experience & Participation team“there was a sense of having led something between us.” Change Dayalso provided the opportunity for staff who would not normally considerthemselves to be ‘leaders’ to step-up and show just what fantastic leadersthey could be.


Appendix C: The Story of Jonathan Griffiths

Who: Jonathan Griffiths, Member of Governing Body of Vale RoyalClinical Commissioning Group

What (Pledge): Jonathan committed to spending the day in a wheelchairin order to appreciate, promote, and raise awareness about theexperiences of wheelchair users and International Wheelchair Day.

Where: Jonathan did everything from a wheelchair – from using the toiletto travelling in a wheelchair-accessible taxi – at his two places of work, theVale Royal Clinical Commissioning Group and Swanlow Practice.

When, pledged for how long: Jonathan spent the day in a wheelchairon Wednesday, March 18, 2013. As part of his Change Day pledge, hethen shared his experience with others on his CCG’s blog:http://www.valeroyalccg.nhs.uk/blog/2004-mobility-and-social-isolationand http://www.valeroyalccg.nhs.uk/blog/news_items/1924-i-may-be-smiling-but-this-is-hard-work.

How Jonathan got involved: A “newbie” to Twitter, Jonathan created aTwitter account at the beginning of 2013, which is where he first learnedabout Change Day. Jonathan immediately knew he wanted to be part ofChange Day but did not know what to pledge. Later, Allison Phillips, aClinical Project Manager, asked Jonathan to participate in InternationalWheelchair Day on March 1. Jonathan was unable to make thecommitment on this date, so he instead made it his pledge to NHSChange Day 2013.

Why he got involved:When Jonathan read the NHS Change Day Tweetsand reviewed its website, its model of distributed leadership appealed tohim. He liked that anyone could commit to being a part of somethinglarger than themselves, connecting their local actions to a nationalcommunity with shared values. He believes in leading from example.“This is how I wish to lead. It’s not for other people. It’s what I believe in;this is me being me.” Change Day afforded him the opportunity “to puthimself out there a little bit.”

Why this pledge: Jonathan wanted to promote International WheelchairDay and share the lessons he learned with others. It was important to himto better understand, even in a limited way, the experience of those whospend their lives in wheelchairs.

How the pledge worked: “I arrived at work at 9am. The wheelchair waswaiting for me. I took some time to work out how get it ready for use,and realized that I needed a spanner to adjust the footplates. The estatesdepartment kindly came to help me. Between us we set them correctly. I hadn’t realized that I needed to be an engineer just to use thewheelchair!

“Just getting to a desk was difficult. The building I work from is old, andwe have no lift. My usual desk is on the second floor. We had arrangedwith the staff working downstairs for me to have somewhere to work, so Iwas sat with another team. I felt disconnected from the people I usuallywork with, unable to just ask a quick question to our Office Manager, orwalk down the corridor to ask someone something.

“I developed a backache from sitting down all morning, and the cuffs onmy shirt sleeves were dirty from self-propelling the chair.


http://www.valeroyalccg.nhs.uk/blog/2004-mobility-and-social-isolation

http://www.valeroyalccg.nhs.uk/blog/news_items/1924-i-may-besmiling-but-this-is-hard-work

http://www.valeroyalccg.nhs.uk/blog/news_items/1924-i-may-besmiling-but-this-is-hard-work

“I negotiated myself into the disabled toilet. Again, easier said than donewith ladders and vacuum cleaners left in the corridors. Once arriving at thetoilet I found a builder filling his bucket from the disabled bathroom sinkafter having removed the u-bend. A small delay was required while hesorted this out!

“Getting through the doors to exit the building was a real challenge. Getting down the ramp was okay, although rolling ‘downhill’ was slightlydisconcerting! Once at the bottom of the slope I had no access out into thecar park because a car was parked in the disabled bay blocking the way out.(As we have no disabled staff assigned to work out of the building, andalready have a car park issue, people have taken to parking in the disabledspaces.) I also discovered that my footplates were too low and catching onthe ramp. I had to rely on someone to wheel me back up the ramp. (He laterinformed me after the event that he nearly dropped the chair and me.) We finally had to move two cars to get me out of the building.

“A wheelchair-accessible taxi arrived on time and I was dealt withefficiently and professionally. Being wheeled up a ramp into the vehiclewhich was then clamped to the floor was an experience, but I felt safeand looked after. Apparently it costs about £5000 to modify a vehicle forwheelchair use. It cost me £22 for a 10-mile journey.

“At one point I tweeted a picture of myself saying, ‘I may be smiling butthis is hard work.’”

Outcomes: This pledge impacted Jonathan on a personal level by developinghis empathy for wheelchair users. “I am much more aware of the difficultiesfacing wheelchair users in just getting about. Everything was so much more

difficult than I ever expected, and I have found new respect for people inwheelchairs who just get on with it and make it look easy.

“Of all the challenges of the day, the social isolation was the worst. I wasunable to be with my team, unable to get to them. I was not expectingthis to feel as difficult as it did.

“And although I might have imagined what it was like spending time in awheelchair, it was only when I did it that I really began to understand.Clearly spending one day in a wheelchair does not mean that I know whatit is really like, but it has increased my understanding a little bit. It certainly increased my respect for wheelchair users.”

During the day, Jonathan’s pledge also affected those working with him.Members of his team were forced to meet on different floors andlocations so that Jonathan had physical access to meetings. “Mycolleagues had to find me a desk on the first floor; they had to move theteam brief downstairs; they had to seek me out in a different locationwhen they had questions. No one seemed to mind, but it did emphasisehow we are not usually set up to manage with a person in a wheelchair.”

Jonathan also asked another team member to chair the meeting as hisNHSCD pledge. “She got to experience what it was like for me to chairour meetings.” Colleagues also stopped to talk to Jonathan about hisexperience throughout the day, curious to learn from his insights. “They wanted to know what it was like.”

Jonathan also shared his experience more broadly via Twitter and blogposts, as well as via a press release and telephone interview with a local


newspaper. He received re-Tweets and comments that buoyed and inspiredhim, and that connected him to those involved in Change Day across thenation. “I felt part of something bigger than myself or my pledge. I built newrelationships as I Tweeted about my experience throughout the day. And Ihave carried on with blogging and Twitter. Change Day was a goodintroduction to the power of social media in connecting us.”

Since Change Day, Jonathan has asked team members to swapperspectives with each other in order to improve their individual andcollective practices. “I asked a receptionist to sit in surgery with me. Then I sat with her to learn about her approach to what she does. By better understanding each other’s concerns, objectives and practices,we were able to come up with a better way to achieve our shared goals.”

Lessons: “What struck me about the day was how the little things whichwe all take for granted became so much more difficult. Things like gettingthrough doors, closing toilet doors behind us, driving a car and climbingstairs. There was one thing, however, which I really wasn’t expecting:social isolation. Being unable to share an office with my usual team, beingunable to call over to the Office Manager to ask what time the meeting is,being unable to nip down the corridor to ask someone their advice. I wasstuck downstairs in a building with no lift, and even if there had been alift, I would have thought twice before making the trip.

“In one meeting that I was chairing, I was only able to access the far endof the room in my wheelchair. The tea and coffee and biscuits were at theother end of the room. I was unable to wheel myself [to the tea] becausethe table and chairs were in my way. And even if I had got there, Icouldn’t have wheeled myself back carrying the cup of tea. I had to relyon others to help me. This took away my feeling of independence, and

sometimes I didn’t want to ask for help. At the same time this made mefeel socially isolated.”

Change in thinking: “When I tell patients who are wheelchair users that Ispent the day in a wheelchair, it immediately improves our relationship. They appreciate that I went to a little effort to better understand their livedexperience, and I appreciate that I only touched on it in a limited way.

“Spending a day in a wheelchair also led me to thinking about theimportance of always placing the person at the centre of what I am tryingto do. Spending time in their shoes, or in this case on their wheels,challenged my views. On the day I tweeted that I thought all NHS staffshould spend time in a wheelchair. I still believe this is true. I challenge youto consider doing this. You may learn something unexpected.”

Change in leading: “I see patients who have mobility issues all the time.I visit them sometimes feeling slightly irritated that they have not mademore of an effort to get to surgery to come and see me. I try and getthrough my visits quickly, feeling the clock ticking, with more workwaiting for me back at surgery… The patients that I am talking about mayspend their whole day at home with carers nipping in two or three times aday, being otherwise left alone, unable to go out, or even sometimesunable to get out of the chair, or out of bed without assistance.Intentionally reducing my mobility for a day has opened my eyes to howawful this can be.”

Because Jonathan feels a greater sense of empathy for them, he spends moretime with them. “When I am on a home visit with someone elderly andhousebound, I know that I might be the only personal contact that patienthas with anyone that day. I accept the cup of tea offered. I ask about things


that go beyond their medical problems. It is good for them, and it connectsme to why I care for others. It helps me see them as people instead of medicalproblems and fosters a better patient-doctor relationship.”

NHS Change Day approach: “I joined this effort through Twitter and theChange Day website. I saw what others were doing across the country,and when I tweeted my experience, other people that I didn’t knowresponded to me. I tweeted ‘wheelchair waiting for me this morning’with a photo of the wheelchair and sent it to @NHSChangeDay and gotTweets back immediately. I felt like I was a part of something bigger thanmyself. I was a part of a national community of like-minded people tryingto improve the NHS in their own ways.

“These actions can trigger other things. Even if for some it is a moraleboosting day, it is worth our spending time to figure out ways to betterappreciate and enjoy the work we are doing.

“People were left to decide what their pledge was themselves. You couldsee what others were doing, but there wasn’t a ‘we want you all to dothis’ approach. Some people did big things, others did little things – thepoint was to do something that you found meaningful and could committo. That was good for ownership reasons. People could say, ‘I thought ofthat, I did that,” rather than being told what to do. You own it, don’tyou? You can run away with it and be your own change maker. I did.

“I think it is okay for Change Day 2014 to roll out the things that workedwell – so long as people are still exercising their own choice. People can beinvited to learn about pledges that could create more meaningful impactor join a pledge that others are doing or support someone else’s pledge.

I think this could be inspirational to some people. Others will want to dotheir own thing.

“It seemed to me like the simplest ideas were the best. I remember seeinga pledge where a provider called on patients in the waiting room ratherthan using his call buzzer. This is a simple but powerful change in day-to-day behaviour. It doesn’t take much to do, but the relational impact onpatient care can be meaningful.

“The pledges open your mind to see that the way things are done doesn’thave to be the way things are done. We all fall into patterns, we assumethey are the best ways to go about things. NHS Change Day encouragesus to question our assumptions – maybe we are right, maybe we arewrong. It makes us learn something. It makes us ask: What can I try next?It certainly made me look at my own ideas around access and patientexperience, and it gave me permission to try new things.

“It is a great example of a bottom up approach. It isn’t your boss telling youthis is how you should improve. You decide for yourself what you want to dodifferently and set a goal. It is like giving employees a day a week to work ontheir own projects. Did you know that Gmail was invented that way? Googleencourages innovation by encouraging its employees to pursue their ideas.You get better ownership if you give people a chance to do that. Bottom upmeans better ownership in the NHS.

“Personally I don’t think this approach is threatening to senior leaders. I can see how others might but they need to get over it. It’s just a differentstyle of leadership. NHS Change Day models distributed leadership. We need to move in that direction as a whole organisation. And we needto look for models of integration that cross health and social care.”


Appendix D: Authors’ Biographies

Kate Hilton, JD, MTSKate Hilton is a Director at ReThink Health.Founded in 2007, ReThink Health is anincubator that supports the emergence andapplication of new ways to accelerate thetransformation of health and health care.ReThink Health works to enable a genuinemetamorphosis within the health system tooccur – one in which different stakeholdergroups come together in unexpected ways toredefine solutions and bring them to action.

At ReThink Health, Kate specializes in the fieldof community engagement and leadership. She designs healthcampaigns, teaches leadership skills, and strategises with leadershipteams to take collective action, particularly in multi-stakeholder settings.Kate’s work with ReThink Health focuses on developing its communityengagement work, distance learning programs, and leadership trainings.Kate is also a Principal in Practice for the Leading Change Project atHarvard University.

Kate currently co-leads ReThink Health’s regional health transformationwork in partnership with Dartmouth-Hitchcock and The DartmouthInstitute in the Upper Valley of New Hampshire and Vermont. She servesas curriculum coordinator and faculty in ReThink Health’s distancelearning program. She is also a coach in a Special Innovations Projectsupported by the Centers for Medicare/Medicaid Services. This projectapplies community engagement skills and systems dynamics insights toimprove outcomes in areas of low performance and high costsassociated with chronic disease states like CHF and COPD.

From 2010-12, Kate led a community mobilisation team to catalyse the Healthy Columbia campaign, exploring the contributions thatorganising can make to the transformation of health and health care inSouth Carolina.

In 2010-11, Kate served as lead coach and trainer on an 18-monthprogram looking at how theory, practice and approaches fromcommunity organising can contribute to quality improvement and costreduction in the NHS. In partnership with colleagues at the NHS Institute,this culminated in an adaptation of an engagement frameworkspecifically for the NHS (Call to Action: Delivering QIPP and achievingcommon purpose through shared values and commitment).

From 2010-12, Kate was the Founding Director of Organising for Healthand designed and led its distance learning course. Kate has coachedleadership teams and led community engagement trainings for healthcare organisations including the Institute for Healthcare Improvement,Centers for Medicare & Medicaid Services, Colorado Foundation forMedical Care, Counties Manukau District Health Board of New Zealand,Harvard Vanguard, Danish Society for Patient Safety, South CarolinaHospital Association, and IHI Open Schools.

Kate taught in Marshall Ganz’s organising course at Harvard KennedySchool in 2004 and 2009; and she co-designed and led the first distancelearning version of the course in 2010. She works closely with Ganz and Leading Change to design curriculum, lead trainings, teach courses, write articles, and coach teams in leadership skills andorganising strategy.


Kate received a J.D. from the University of Wisconsin Law School in2008, an M.T.S. from Harvard Divinity School in 2004, and an A.B. fromDartmouth College in 1999. She is licensed to practice law in Wisconsinand Massachusetts. She lives with her husband, Andrew, son, Hans, andLabrador retriever, Jethro, in Lyme, New Hampshire.

Chris Lawrence-Pietroni, BA, MA, MPAChris is a Director of Leading Communities – a neworganisation that works at the intersection betweencommunity engagement, systems leadership andservice design. He works mainly across health, socialcare and local government in the U.S. and U.K. Heis also a Senior Associate at the Institute of LocalGovernment Studies (INLOGOV) at BirminghamUniversity.

Chris is currently supporting Coventry City Council and BirminghamCommunity Health Services Trust as part of the national Local VisionProgramme. Both oganisations, their partners and communities areapplying social movement theory and practices to major public health challenges.

Chris collaborates with ReThink Health in the U.S. and has recentlycoached Quality Improvement Organisations in Louisiana and Baltimoreas part of a Center for Medicare Studies Special Innovation Project. The project focused on applying both community organising and systemsdynamics insights to improving outcomes in areas of low performanceand high cost associated with chronic disease states such as CHF and COPD.

As a Senior Associate at INLOGOV Chris consults to a number of localauthorities on organisational design and leadership development(particularly as it relates to enabling co-production) and is a core facultymember on the National Graduate Development Programme for LocalGovernment.

Chris has worked extensively with the National Health Service developingcapacity around community organising and mobilising. Most recentlyChris led trainings for the National Institute of Clinical Excellence and theHealth Protection Agency to enable them to incorporate an organisingtheory of change into their work on hospital acquired infections. He waspreviously a coach and trainer on an 18-month program looking at howtheory, practice and approaches from community organising cancontribute to quality improvement and cost reduction in the NHS. Inpartnership with colleagues at the NHS Institute, this culminated in anadaptation of the organising/mobilising framework specifically for theNHS (Call to Action: Delivering QIPP and achieving common purposethrough shared values and commitment).

Chris has delivered community organising trainings in Serbia (where thecampaign focus was on reducing corruption in healthcare) and been afacilitator for the Harvard Kennedy School’s Leadership in the 21stCentury Executive Education Program.

Chris has worked extensively in the non-profit and public sector in theU.K., and until July 2009 he was Director of Corporate Strategy andPubic Affairs for the Local Government Association. He then spent a yearstudying at the Harvard Kennedy School and graduated with a Mastersin Public Administration when he was awarded the Lucius N. LittauerFellowship. He holds degrees in History from the Universities of Oxford(BA) and Warwick (MA – with Distinction).


Published by: NHS Improving Quality - Publication date: November 2013.© NHS Improving Quality (2013). All rights reserved. Please note that this product or material must not be used for the purposes of fi nancial or commercial gain, including, without limitation, sale of the products or materials to any person.

The focus of this report is on an improvement initiative developed by the NHS Institute for Innovation and Improvement (NHSI); a national body established in July 2005 to support the transformation of the NHS, through innovation, improvement and the adoption of best practice. NHS Institute for Innovation and Improvement closed on 31 March 2013. NHS Improving Quality (NHS IQ) is the organisation now responsible for driving improvement across the NHS. For further information, go to www.nhsiq.nhs.uk. For more information about NHS Change Day, go to www.changeday.nhs.uk.

www.changeday.nhs.uk #NHSChangeDay

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the story of change day

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