1.NHS CHANGE DAY Do something better togetherLeaders Everywhere The story of NHS Change Day A learning report 2013 www.changeday.nhs.uk #NHSChangeDayBy Kate B. Hilton & Chris Lawrence-Pietroni NHS Change Day is supported and coordinated by NHS Improving Quality.

2. PURPOSE, DESIGN & AUTHORS OF THE LEARNING REPORT The purpose of this report is to explore what can be learned from NHS Change Day 2013. Its intent is to summarize the lessons described by those who took part in NHS Change Day; it is not a formal or independent evaluation. The report offers a narrative of what happened, explores the ways in which people led and pledged their support of NHS Change Day, highlights lessons learned, and discusses the strengths and challenges of this approach. The report draws on interviews with core leaders, clinical and non-clinical staff, the NHS Change Day website and a catalogue of materials. It describes the immediate and ongoing impact of NHS Change Day through examples and stories that raise strategic questions for those involved in future Change Days and similar efforts.Kate B. Hilton and Christopher Lawrence-Pietroni authored this report. In 2010-11, Kate and Chris supported the QIPP workstream team on mobilising for cost and quality by developing distributed leadership skills and adapting a community organizing framework to the NHS (resulting in Call to Action: Delivering QIPP and achieving common purpose through shared values and commitment). Having been mentored for years by longtime organiser, Marshall Ganz, Kate and Chris consult with organisations and voluntary multi-stakeholder groups to achieve shared purpose around health transformation. Their biographies are attached as appendices to this report. Kate and Chris wish to express their gratitute for the opportunity to learn alongside those participating in NHS Change Day, and thank all those who kindly volunteered their time to share their insights, experiences and stories.Front cover: Picture taken on NHS Change Day 2013 at Healthcare Innovation Expo.2Leaders Everywhere The Story of NHS Change Day 3. CONTENTS EXECUTIVE SUMMARY4INTRODUCTION & ORGANISATION OF THE LEARNING REPORT7CHAPTER 1: THE NATIONAL STORY 1.1 A Time of Enormous Challenge 1.2 The Birth of NHS Change Day 1.3 From Zero to 189,000 Pledges 1.4 Summary of Quantitative Research and Results11 11 12 14 16CHAPTER 2: THE PLEDGE MAKERS STORY 2.1 The Story of NHS Arden Commissioning Support 2.2.The Story of Open Minds Alliance CIC 2.3 The Story of Derbyshire Community Health Services Trust 2.4 The Story of Steve Fairman, NHS England19 19 22 24 28CHAPTER 3: LEARNING FROM NHS CHANGE DAY 2013 3.1 Impact or Design and Outcomes? 3.2 Design: NHS Change Day, Social Movements and Hierarchy 3.3 Outcomes: Distributed Leadership 3.4 Outcomes: Relationships31 31 33 33 36Leaders Everywhere The Story of NHS Change Day3.5 Outcomes: Weak & Strong Ties 3.6 Outcomes: Voluntary Action 3.7 Outcomes: Mobilisation around Shared Values 3.8 Outcomes: Collective Action 3.9 Outcomes: Social Media 3.10 Outcomes: A Special Kind of Grasstops Leadership 3.11 Outcomes: A Dual Operating System38 39 40 41 42 44 47CONCLUSION: LEADERS EVERYWHERE49RECOMMENDATIONS51REFERENCES55APPENDICES Appendix A: The Story of Barking, Havering and Redbridge University Hospitals NHS Trust Appendix B: The Story of Birmingham Childrens Hospital Appendix C: The Story of Jonathan Griffiths Appendix D: Authors Biographies57 57 63 66 703 4. EXECUTIVE SUMMARY NHS Change Day 2013 was the biggest day of collective action for improvement in the history of the NHS. A countrywide event in England, NHS Change Day was a grassroots initiative devised and driven by a small group of emerging clinicians and improvement leaders. Their idea was to create a mass movement of National Health Service (NHS) staff demonstrating the difference they can make by one simple act, proving that large-scale improvement is possible. The NHS Change Day core leadership team applied and adapted social movement theory, skills and practices associated with community organising and made use of social media to secure voluntary pledges from NHS staff and patients to take a specific improvement or innovation action on or around 13 March 2013. The Change Day team set themselves the goal of securing 65,000 pledges, 1000 for each year of the NHS. Over 189,000 pledges were secured on the online pledge-wall alone.Learning from NHS Change Day 2013 The most significant learning from NHS Change Day is that change of this kind is possible; the most significant impact is that tens of thousands of staff have now had the experience of taking part in collective action for change. NHS Change Day was an entirely voluntary effort that invited staff to take action on something that they were passionate about. It intentionally drew on shared values, and in doing so, it unlocked willing commitment to act rather than hierarchical compliance. Putting shared values at the heart of the Change Day provided an authentic call to action to which others with a similar outlook responded. It made Change Day not only an opportunity to do something that would be of benefit to others, but also to express support for the NHS as an institution and the shared values that it represents.Change Day occurred in a context in which the NHS was under great financial, organisational and reputational strain. This combination of factors created a climate in which NHS staff were under internal pressure and negative external scrutiny. NHS Change Day 2013 connected with that moment, providing an opportunity to transform anger or frustration into constructive action.NHS Change Day created a sense of urgency by focusing on a single day of collective action. In many cases Change Day provided the necessary prompt to galvanise and amplify activity that was already planned. Narrative skills were used to heighten and maintain this urgency and to sustain motivation.This learning report was commissioned to tell the story and capture the learning from NHS Change Day 2013. It draws on interviews with core leaders, clinical and non-clinical staff, the NHS Change Day website and a catalogue of materials. It describes the immediate and ongoing impact of NHS Change Day through examples and stories that raise strategic questions for those involved in future Change Days and similar efforts.NHS Change Day had a low threshold for participation encouraging pledge-makers to identify their own action rather than sign up to a single national initiative. This reinforced the model of distributed leadership intentionally applied by the NHS Change Day team, designed to support the development of leaders everywhere. The design of NHS Change Day was unique precisely because it drew together networks of4Leaders Everywhere The Story of NHS Change Day 5. grassroots leaders while also enabling leaders with positional authority to role model change leadership in a new way. No permission was sought or given for NHS Change Day to take place; it arose from the initiative of those motivated to take part. In a traditionally hierarchical environment like the NHS this modelled a profound shift in thinking and behaviour. NHS Change Day was designed to be relational, which is one of the reasons it was so successful. Off-line teams made commitments to each other supported by the online pledges made on the Change Day website. The social media presence supported the development of a community through one-to-one communication via Twitter, shared YouTube videos and other interactions. The relational nature of Change Day extended to many of the pledges themselves. A key insight arising from this experience is the importance of face-to-face human interaction not only in relation to patient care but also feedback and communication between the NHS and the public and amongst 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 new resources on which NHS Change Day 2014 can draw.Leaders Everywhere The Story of NHS Change DayAs with many social movements, young leaders played a particularly important role in providing the energy that initiated NHS Change Day. However, NHS Change Day was simultaneously built on a foundation of learning about social movements and the application and adaptation of community organising skills in a healthcare setting amongst improvement leaders over many years. In September 2013, NHS Change Day was a winner in the Harvard Business Review / McKinsey Leaders Everywhere Challenge.Conclusion NHS Change Day offers an example of how new leadership can be developed and deployed in healthcare. This model enables distributed leadership to flourish while not ignoring the realities of hierarchical structures and processes. There is often a tension between the commitment-driven volunteerism of a collective day of action which can be unpredictable and the temptation by senior leaders to require certainty, specified results or perceived success. In learning to embrace this tension, and to resist the pull towards more familiar behaviours and processes, the possibility emerges for a new kind of organisation that has at its disposal both the standardising potential of hierarchy and the relational potential of networks.5 6. Summary Recommendations Engaging with existing NHS processes: NHS Change Day 2014 should remain outside the formal NHS communication, improvement, training or management structures. Senior Leaders: Senior leaders should be encouraged to pledge as part of NHS Change Day 2014 and should take the opportunity to model the value of enabling others to lead using their positional authority to hold up the successes and stories of pledge-makers. Structure: NHS Change Day 2014 should develop a more intentional structure of distributed leadership that allows teams throughout the country to take responsibility for particular aspects of the overall strategy (based on geography, professional groups, particular pledges, necessary functions or some combination). Their roles should be clearly defined and the core leadership team should in part be drawn from them. Skills and capacity: Planning for NHS Change Day 2014 should make the most of new skills that have been developed by creating opportunities for them to be passed on to others through trainings, webinars, online skills sharing, printed and online resources etc. Emerging leaders: The growth strategy for NHS Change Day 2014 should include a focus on identifying and recruiting young leaders from all parts of the NHS. Patients and their families: The strategy for NHS Change Day 2014 should consider what resources patients, their families and citizens in general can contribute to the overall effort, as well as its leadership.6Integrate online and offline strategies: The strategy for NHS Change Day 2014 should include an online/offline element that draws inspiration from contemporary campaigns and social movements. Build on successes: NHS Change Day 2014 should build on the successful pledges in 2013, particularly those that mobilised large numbers of people within a particular organisation or locality. Campaign approach: An annual campaign to hit a target number of pledges on a particular day each year is central to the Change Day design. While making room for new thinking, leadership and learning, a longerterm ten-year strategy for Change Day can help guide its growth with year-round activity. Goals and metrics: NHS Change Day 2014 should set an even more ambitious goal for the number of pledges secured. Additional metrics should be considered including: impact measures directly from pledges, impact measures of effects of pledges on involved patients and staff, and metrics around NHS Change Day design elements. Opportunities for research: Change Day leadership, pledge-makers and researchers should come together to pursue research partnerships, particularly around demonstrating impact from pledges and pledgemakers involved in Change Day. Global movement: The NHS should invite others to join them in a worldwide Change Day with no one particular organisational affiliation, but the same approach and objectives.Leaders Everywhere The Story of NHS Change Day 7. INTRODUCTION & ORGANISATION OF THE LEARNING REPORT NHS Change Day 2013 was the biggest day of collective action for improvement in the history of the NHS. A countrywide event in England, NHS Change Day was a grassroots initiative devised and driven by a small group of improvement leaders and young and emergent trainee clinicians. Their idea was to create a mass movement of NHS staff demonstrating the difference they can make by one simple act, proving that large-scale improvement is possible. The effort was designed to engage the frontline in individual and team pledges to improve patient experiences or clinical outcomes by spreading and adopting best practices and championing innovation. The aim was for 65,000 pledges to be made, 65 being the number of years the NHS has been in existence. Over 189,000 pledges were made. This report explores some of the learning from this inspiring effort. It is organized into three chapters: (1) narrative of Change Day; (2) learning from pledges, and (3) lessons from the approach. In Chapter One, we offer a narrative of Change Day by describing the challenges facing the NHS at the time, the birth of Change Day as an idea, the leadership that took it forward, their strategy to reach their goal, and a summary of quantitative results. In Chapter Two, we offer the qualitative examples of four pledges to learn what Change Day meant to pledge-makers, and what pledge-makers meant to Change Day. In Chapter Three, we explore our learning about this approach to change by examining its design elements and considering the range of outcomes that flowed from them, the challenges and limitations that emerged, and opportunities for development in the future. We conclude this report with a brief summary of what we view as our greatest takeaways from NHS Change Day and its implication for health care organisations the world over.Leaders Everywhere The Story of NHS Change DayHOW TO READ THIS REPORT NHS Change Day 2013 was the biggest day of collective action for improvement in the history of the NHS. A countrywide event in England, NHS Change Day was a grassroots initiative devised and driven by a small group of improvement leaders and young and emergent trainee clinicians. Their idea was to create a mass movement of NHS staff demonstrating the difference they can make by one simple act, proving that large-scale improvement is possible. In September 2013 NHS Change Day was a winner in the Harvard Business Review/McKinsey Leaders Everywhere Challenge. The effort was designed to engage frontline staff in individual and team pledges to improve patient experiences or clinical outcomes by spreading and adopting best practices and championing innovation. The aim was for 65,000 pledges, 65 being the number of years the NHS has been in existence. In the event over 189,000 pledges were made.Chapter 1: The National Story Stories are at the heart of all successful social movements; they are used to call others to action, to sustain motivation in difficult times and to celebrate what has been achieved. In Chapter 1, we tell the story of NHS Change Day from the perspective of the national leadership team that brought it into being. How and why did it happen? How did this team come together? How did they come up with the idea? How did they work together? What challenges did they face? How did they overcome them? What have they learned and what would they do differently? If these questions are of interest, youll find answers in sections 1.1-1.3. Quantitative results of NHS Change Day 2013 can be found in section 1.4.7 8. Chapter 2: The Pledge-Makers Story Stories are endlessly variable and can be retold in many ways. In Chapter 2, we tell the story of NHS Change Day from the perspective of the people who made it happen on the ground the pledge-makers. To do this, we dive into four case studies, each of which illustrates a different kind of pledge with diverse challenges, choices, outcomes and learning. In section 2.1 the Story of NHS Arden Commissioning Support explores the unexpected benefits of participating in Change Day from a group that did not initially connect with its approach, and the surprisingly powerful impact of a pledge that engaged staff and citizens in face-to-face relationships. In section 2.2 the Story of Open Minds Alliance Community Interest Company reveals how a single pledge led to over 50,000 supporters, and how Change Day enabled an organisation outside the NHS to build thousands of relationships inside the NHS, each of which has the potential to improve the health and wellbeing of some of the most vulnerable people in England. In section 2.3 the Story of Derbyshire Community Health Service Trust illustrates how Change Day was used as a catalyst to amplify work that is already underway, how the creativity of staff was unleashed (look out for the Harlem Shuffle), and how supporting pledges at a local level helped to ensure sustainable impact.8In section 2.4 the Story of Steve Fairman, NHS England shows how action by a single pledge-maker had unpredictable knock-on effect that led to a chain of new insights and relationships, and the impact of a pledge that at its simplest involved spending time in someone elses shoes. Three additional case studies can be found in Appendices A-C. In Appendix A the Story of Barking, Havering and Redbridge University Hospitals NHS Trust explores the pledges of three different leaders and how they worked to enable others to exercise leadership. In Appendix B the Story of Birmingham Childrens Hospital illustrates the impact that a single enthusiastic individual can have by motivating others, and how an institution like a hospital can replicate the Change Day model locally, generating hundreds of pledges and sustained change. In Appendix C the Story of Jonathan Griffiths shows how social media played a role in raising awareness of Change Day and building a national community of collective actors, as a GP spent the day in a wheelchair in order to better understand one subset of patients. We have drawn extensively on lessons and examples from the appended case studies in Chapter 3 of this report and included them in full as an additional resource.Leaders Everywhere The Story of NHS Change Day 9. Chapter 3: Learning from NHS Change Day 2013 This report aims to tell the story of NHS Change Day 2013 and to extract the learning from that story. In Chapter 3 we draw the learning together. Section 3.1 Impact or Design and Outcomes? looks at the thorny issue of how to measure the success of NHS Change Day 2013. What was its short, medium and long-term impact, and what are the best metrics for judging it? Is it possible to measure traditional improvement impacts and how valuable would it be to measure new capacity for action? What metrics should NHS Change Day 2014 adopt? Section 3.2 Design: NHS Change Day, Social Movements and Hierarchy considers what effect the application of social movement theory had on the design of NHS Change Day, how this was adapted for use in a vast hierarchical organisation, and what effect this had on the kinds of outcomes that NHS Change Day can enable. Section 3.3 Outcomes: Distributed Leadership explores the model of leadership used and developed by NHS Change Day, the extent to which this is valuable within the NHS and the challenges this poses. Section 3.4 Outcomes: Relationships looks at the importance of offline relationships in building and sustaining NHS Change Day, recruiting new leadership to it and the legacy of these relationships in terms of new social capital. Section 3.5 Outcomes: Weak & Strong Ties digs a little deeper into the nature of the relationships formed through NHS Change Day, the particular value these added to the effort and the value they could add to the NHS in future.Leaders Everywhere The Story of NHS Change DaySection 3.6 Outcomes: Voluntary Action investigates a fundamental principle that underpinned Change Day, what difference it made to outcomes and the challenges of sustaining this within the NHS. Section 3.7 Outcomes: Mobilisation around Shared Values looks at the positive vision of NHS Change Day and how this was used as a way of motivating others to take action through narrative and stories. Section 3.8 Outcomes: Collective Action shares learning from pledgemakers and others about the experience of participating in a single day of action and the effect that this had. Section 3.9 Outcomes: Social Media draws together insights on the extraordinary role that a range of social media and online technology played in enabling Change Day to happen, how the potential of social media was actively exploited at all levels and what else might be done in future. Section 3.10 Outcomes: A Special Kind of Grasstops Leadership focuses on what NHS Change Day tells us about the role of senior leaders in mobilisation efforts and the implications that this has for the kind of leadership that they may need to offer day-in day-out. Section 3.11 Outcomes: A Dual Operating System extends learning about leadership into the kinds of formal and informal structures that were used by NHS Change Day and what this suggests about the value for the NHS of more intentionally operating through hierarchy and networks simultaneously.9 10. Stuart Sutton GP, Becton Surgery, East London Core leadership team Originator of the first tweet with Helen BevanConclusion: Leaders EverywhereRecommendationsOur conclusion is not only that NHS Change Day was an extraordinary event which created significant new capacity but also that it helped to model the development of distributed leadership that makes the most of the standardising potential of hierarchy and the relational potential of networks.We include twelve recommendations that draw on the learning from NHS Change Day 2012. These are intended as a contribution to NHS Change Day 2014 and to assist others around the world interested in applying a Change Day approach.10Leaders Everywhere The Story of NHS Change Day 11. CHAPTER 1: THE NATIONAL STORY 1.1 A Time of Enormous Challenge Change Day occurred in a context in which the NHS was under great financial, organisational and reputational strain. Although the government had protected NHS funding, the service as a whole was looking to achieve 20bn in efficiency savings by 2015. At the same time, the 2011 Health and Social Care Act had ushered in a period of restructuring intended to shift resources towards primary care by giving responsibility for commissioning most services to Clinical Commissioning Groups led by GPs. Amidst these financial and structural challenges, NHS staff like other public service employees were facing the consequences of the governments austerity programme in the form of an agreement to a twoyear pay freeze in order to avoid compulsory redundancies. Concern about patient safety and the standard of care provided the constant background to this period of challenge for the NHS with regular media coverage of perceived failings and shortcomings. The long-running series of inquiries into major failings at Mid-Staffordshire NHS Foundation Trust exemplified this concern and published a series of damning reports with wide-ranging recommendations.1 The inquiry was due to issue its final report in February 2013 one month before NHS Change Day. This combination of factors created a climate in which NHS staff were under considerable internal pressure and frequently negative external scrutiny. In the midst of this reality, many cynics dismissed the Change Day effort. Some felt that committing to a pledge was another way for line managers to get people to comply with improvement measures by dressing it up as applying social movement theory. Others argued, It is already our job to improve the NHS; why should I treat this day differently from any other? Still others worried that it was a politically charged effort 1and wished to remain neutral. Some were too exhausted by their day jobs, admitting that they didnt want one more thing to have to do. And others felt that the effort would not produce measurable impact, citing pledges as insignificant. These cynics watched from the sidelines as an explosion of energy and commitment from frontline staff created a different reality. Jackie Lynton from the NHS Change Day core leadership team 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 mood amongst those facing financial pressures, reorganisation and the imminent publication of the final Francis Report into the failings at Mid-Staffordshire NHS Foundation Trust. The timing suggests the importance of the sense of urgency that surrounded NHS Change Day, as it provided an opportunity to transform peoples 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 than the Royal Family or the armed forces (Katwala, NHS featured in the Olympics 2012 2013). Politician Nigel Lawson famously described the NHS as the closest thing the English have to a national religion (Katwala, 2011). It is difficult to imagine any other country thatThe inquiry was led by Robert Francis QC, and the reports are referred to as the Francis report.Leaders Everywhere The Story of NHS Change Day11 12. would, without irony, celebrate its health service in front of the world at the Opening Ceremony of the Olympic Games. NHS Change Day harnessed its peoples pride and passion for a system designed to take care of its own. The NHS is also the biggest health system in the world, serving the needs of a population of 54 million people.2 The sixth biggest employer in the world, only the U.S. Department of Defense, the Peoples Liberation Army of China, Walmart, and McDonalds have more people (Alexander, 2012). Everyday a million patients use the services of the NHS. It is a massive complex system and as such, not easy to change. Yet NHS Change Day marked the single biggest improvement event in any organisation in the world. Why? Each and every one of its workforce of 1.7 million employees were treated as potential leaders of change.1.2 The Birth of NHS Change Day The story begins in 2012 when a conversation began on Twitter between a GP and healthcare improvement thought leader. GP Stuart Sutton had just attended Helen Bevans talk on Building Contagious Commitment to Change as part of the learning programme run for Darzi Fellows by the Kings Fund. Helen had worked for years to apply social movement principles to improving health care, in part as a response to some existing change initiatives using Lean, Six Sigma and other industry approaches. Trained in community organizing methods, Helen encouraged others in the NHS to learn from leaders of great social movements, people who had few resources, no hierarchical and positional power, but who delivered results by building power through collective action.112During her presentation, Helen asked the audience to describe the projects that they were working on. 70 percent described cost-benefit efficiency projects; and 30 percent described projects focused on quality, patient care or the safety-experience. Helen then challenged her audience to consider how the design of projects generates commitment from others. Was anyone up for doing something differently? Helens provocation got Stuart thinking, and after the training he and Helen exchanged Tweets. They agreed to meet and talk more about what mobilising young clinicians across the NHS might look like. Paediatric trainee, Damian Roland, joined the conversation; and Helen encouraged Stuart and Damian to take seriously their passion to make a difference for patients. Even though emerging clinicians like Stuart and Damian might be perceived as powerless and at the bottom of the NHS hierarchy, Helen understood that young people historically drive change, and that effective leadership comes from within a constituency, not outside it. In fact, in 1948, it was the new generation of doctors who lived through the war that were instrumental in overthrowing the established order and securing the establishment of the NHS in the first place. Stuart and Damian recruited other emerging clinical leaders to explore ideas over the course of two conference calls. The make-up of this group reflected the engagement of Generation Y, who in previous years had been focused on completing their clinical training and kick-starting their careers. This growing cadre of younger leaders were active on social media, ready to engage in change, and passionate about making a difference for patients.The inquiry was led by Robert Francis QC, and the reports are referred to as the Francis report.Leaders Everywhere The Story of NHS Change Day 13. They ultimately took their inspiration for Change Day from Earth Hour, a worldwide event organized by the World Wide Fund for Nature (WWF), that encourages households and businesses to turn off their non-essential lights for more than one hour to raise awareness about the need for action on climate change. The first event took place at the end of March 2007, when 2.2 million residents of Sydney participated by turning off all non-essential lights. Following Sydneys lead, many other cities around the world adopted the event. By 2012, it was taking place in more than 7000 cities and towns across 152 countries and territories. The emerging clinical leaders initial questions were about what the NHS could do that was equivalent to turning the lights off. They asked themselves, What should we use as our goal? Should we identify a specific action that we want everyone to take, or should we leave it to people to take action that is meaningful to them? How will we measure outcomes? 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 that Earth Hour is an umbrella movement that brings many organisations and activists together in a common cause. NHS Change Day is a movement largely inside and alongside a hierarchical system. Jackie Lynton played a special leadership role in bringing this about. As Lead Associate for Thought Leadership & Change Model at the then-NHS Institute for Innovation and Improvement, Jackie sat in on an early conference call among the emerging clinical leaders. She immediately recognized their idea as a mobilisation project and saw its potential. Jackie established a strong coaching relationship with Damian, who initially wanted to give people a menu of two to three national pledges to choose from, in part motivated by a desire to measure impact.Leaders Everywhere The Story of NHS Change DayBased on her own experience as a former clinician, Jackie encouraged him to consider the power of not telling people what to do but of giving them the opportunity to decide for themselves. With her coaching, the emerging clinical leaders together decided it was critical to maintain a balance between igniting frontline engagement and using the leverage of the hierarchy to make positive change happen as a voluntary grassroots effort. They wanted to create leaders everywhere. Out of their initial leadership grew a core leadership team that recruited other members with particular technical and organisational expertise. The role of the core leadership team was to organise and mobilise people and put in place a range of channels, activities and platforms particularly through relationships and social media to enable individuals amongst the NHS and its supporters to join the effort. Members of the core team included: Damian Roland (Paediatric Senior Registrar), Stuart Sutton (GP), Pollyanna Jones (NHS Graduate Management Trainee), Kat Trimble (PR and Communications), Jacqui Fowler (Social Media and Knowledge Management), Joe McCrea (Social Media Strategy), and a team of improvement leaders from the NHS Institute including Helen Bevan, Rachel Douglas-Clark, Michaela Firth, Stuart Hill, Jackie Lynton, and Alan Nobbs. The ongoing coaching dynamic between the emerging clinical leaders and improvement leaders played an important role. The improvement leaders provoked the clinicians to take action, serve as role models, and act as spokespersons. Meanwhile the improvement leaders helped the clinicians develop leadership skills and a campaign structure. In turn, the clinicians provided leadership from within the frontlines of the NHS. They provided the effort with real credibility among the clinical community.13 14. Over the course of the next few months, the core leadership team worked together in the following way: they had one half-day strategy session to agree to the goal, shared purpose and campaign plan; a weekly 1-hour WebEx meeting to agree to ongoing tactics and actions; hours of spontaneous coaching and support across the team; calls to action to keep their energy up and motivate each other; and support from an oversight group made up of senior leaders. Here is what they did with that.1.3 From Zero to 189,000 Pledges The first challenge the team faced was to decide on a commitment-based goal. In other words, they could not create leaders everywhere through compliance; NHS Change day had to be underpinned by intrinsic motivation around shared values, one that anyone could commit to. Initially they thought of asking everyone to take part to develop an improvement project inspired by some of the best practices approaches that already existed. Some thought a target of 500 projects might be aspirational but reasonable. Others thought they could be more ambitious. At a strategy meeting, the goal of achieving 65,000 online pledges was agreed 1,000 for every year of the NHS. This was a nerve-wracking choice. How would they secure that level of commitment? After brainstorming various ways in which this could be brought about, they developed the concept of a single day of action. They had six months to get there. This is the campaign chart that sets out the leadership teams timeline for NHS Change Day and the mountain top goal of 65,000 pledges.14The next challenge point came in December. According to Alan Nobbs, the team was working furiously to answer strategic questions like How do we get the message out? How do we filter it down? How do we help people focus on pledges that are important? How do we structure leadership, and how do we practice leadership? How do we enable others? Stuart Hill adds, We were also facing our own challenges and uncertainty. With the restructuring of the NHS, many of us faced redundancy and redeployment. I personally felt challenged in giving Change Day the energy it needed in the midst of all that noise.Leaders Everywhere The Story of NHS Change Day 15. Damian Roland agrees. We did struggle in December. We were hugely behind schedule, we were revisiting the strategic direction, and challenging personality dynamics began to emerge within the team. Jackie Lynton, in particular, exercised leadership by renewing our relationships, shared purpose, and values to forge a new level of trust. Jackie Lynton looked at her role as an improvement leader in a particular way. I saw my role as fending off internal and external resistance to enable our young leaders to unleash their energy. It was about enabling them 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 am here to enable you, I will deal with the rubbish. That is what our pledgemakers did too. Their pledges say the same thing to our patients. The New Year was a New Year. January marked the public launch of NHS Change Day, and that in and of itself energized the team. Along with it was the public release of the NHS Change Day video and website. The team saw its own story of us personified in the urgent call to action brought alive on camera and online. Stuart Sutton pointed out, The public launch was a breakthrough moment. We got our narrative right, we made the connection to people on the frontlines real, and the film was a brilliant recruitment tool. When I showed it to people, they got it! After the launch of Change Day, the number of pledges started slowly rising. Although the core team had built a lot of relationships and asked many organisations and individuals to make pledges before or on the day itself, nothing could have prepared them for what happened. In the final month before 13 March, Change Day took off.Leaders Everywhere The Story of NHS Change DayThe Francis Report was released on 6 February. It provided an urgent challenge to call people to action. Feedback and requests for support began to pour in from organisations and individuals. Social media channels began to build traction and traffic. On 14 February, the total was 5,000. By 21 February it had grown to 43,000, and by t March it stood at 80,169 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 pledges registered on the website double the target. Liz Saunders from the healthcare policy think tank, the Kings Fund, blogged and tweeted on the evening before NHS Change Day: If ever youre losing faith that there is the energy to make a difference in the NHS there are more than 130,000 pledges on there, people actively choosing to make a difference to the services they provide and to patient care. Its uplifting. Change Day pledges poured into the online site throughout the day. The focus of NHS Change Day was England, but people caught the spirit in Ireland and made over 13,000 pledges from there. By the end of Change Day, 182,000 pledges had been received. Over 50,000 had come in on the day itself. A further 1,000 were added the day afterward, and a further 7,000 before the end of March hitting a total of 189,000 pledges listed on the Pledge Wall. That does not account for those who did not list their pledge, which is estimated at over 300,000.15 16. The success of Change Day led well-known NHS commentator, Roy Lilley, to declare: Sometimes an event comes along that simply and fundamentally changes things. They call it a gamechanger. The dictionary definition is a newly introduced element or factor that changes an existing situation or activity in a significant way. Well, I think we have a new Gamechanger. Its called NHS Change Day. It happened this week, and it came from the NHS grassroots.1.4 Summary of Quantitative Research & Results What did the effort result in? What can be gleaned from the patterns within the pledges? The most profound finding was that it can be done. NHS staff can be mobilised to take action around shared values. Over 189,000 pledges were submitted to the NHS Change Day website, and this total was a fraction of the pledges made and carried out that day. As Joe McCrea, the Social Lead of the core leadership team, quipped, This thing could have been a heroic failure in which case lots of the people who are now saying that they were always supporters would have been pillorying the core team! Since March, a quantitative analysis of the pledges was conducted. Survey research shows that the primary motivation for people to get involved in Change Day was to improve patient care, closely followed by I wanted to make a difference, and I wanted to learn from others. In contrast, the two least motivating factors to get involved in Change Day were because I was told to and because I was asked to. This finding demonstrates that intrinsic motivation around share values was critical to Change Days success, not strategies based on compulsion, compliance or exhortation. 54 percent of pledges on the website involved action taken by a single individual; 71 percent involved fewer than nine people; and 94 percent involved fewer than 50 people.16Leaders Everywhere The Story of NHS Change Day 17. Overall, 25 percent of NHS organisations took part. NHS Trusts led the way, in addition to wide support received from NHS-aligned organisations and individuals. There is still room for improvement for engagement at CCGs and GP practices in particular, as only 5 percent of CCGs and 0.1 percent of GP practices were engaged (see left). 68 percent of pledges focused on better patient care or spreading innovation. 10 percent targeted personal development; 10 percent on using services effective; 7 percent on celebrating services; and 5 percent on implementing integration (see left). 36 pledges encompassed almost 3,500 people involved in simply smiling with fellow patients or staff (see below).Leaders Everywhere The Story of NHS Change Day17 18. Victoria Stead, Receptionist, Becton Surgery, East LondonOther metrics and patterns have been summarized in The Difference a Day Makes Interim Report from NHS Change Day, published in May 2013, Biggest Ever Day of Collective Action to Improve Healthcare that Started with a Tweet posted to the Management Innovation website in June 2013, and What Did NHS Change Day Pledges Tell Us About What Matters to Staff and Patients? submitted in June 2013. These publications also include metrics around the use of social media, a topic that is discussed in Chapter 3 of this report.18But what can we learn from pledge-makers themselves? This is where the spirit and soul of NHS Change Day was made real, where the action made a difference to patients and practices. The above-mentioned NHS Change Day publications describe many excellent and inspiring examples of pledges received. This report does not. Instead, it looks carefully at four different pledges and draws out the qualitative learning from pledge-makers.Leaders Everywhere The Story of NHS Change Day 19. CHAPTER 2: THE PLEDGE-MAKERS STORY One version of the NHS Change Day story is what happened to initiate it and enable it to grow. This is the story that we told in Chapter 1. Another version of the story is about pledge-makers on the ground and how their actions made Change Day real to NHS staff and patients. In this chapter we look at four distinct pledges in detail to understand their stories and draw out the lessons they can teach us. These pledges come from (1) NHS Arden Commissioning Support, (2) Open Minds Alliance Community Interest Company, (3) Derbyshire Community Health Services Trust, and (4) Steve Fairman of NHS England. (Three additional pledge-makers stories are included in Appendices A-C; and we draw on some of their learning in Chapter 3.)Anna Burns, the Director of Strategy & Engagement at the NHS South Warwickshire CCG, explained: Volunteers employed a four-step discussion with individual members of the public that drew on the importance of patient-feedback as outlined in the Francis Report. First, we told them, Today is NHS Change Day. If you could make a change to your local NHS, what would it be? Then we asked, How well do you feel the NHS listens to you? Next we used it as an opportunity to explain the restructuring of CCGs and how it would affect them. Last we recruited volunteers to serve as Health Champions. Everyone had a clipboard and discussion form for responses. We spent about twenty minutes with each person, and spoke with a total of 450 people.Before exploring these examples, it is important to note that the behind-thescenes work of the leadership team was invisible to almost all pledgemakers. Most were exposed to the website, a video, possibly an email or a Tweet. 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 it real, to link existing local work to national purpose, or to step outside of habit and try something new without asking anyone for permission.A logistics team coordinated with contacts at each local site, secured public liability insurance, staffed each site with volunteer coordinators, and provided the requisite materials to each volunteer. Although volunteers approached members of the public individually, they were assigned to subgroups of two or three in order to support one another. The leadership team recruited volunteers via email and personal asks and thanked everyone afterwards.2.1 The Story of NHS Arden Commissioning SupportWhy this pledge: Rebecca Davidson, the Communications and Engagement Lead, explained their reasoning. In response to the Francis Report, we translated our pledge as going into the community to ask what changes the public would like to see and how well the NHS listens to them and their concerns. Change Day was also happening during a huge time of change with the establishment of CCGs. It was a timely reminder to the public about the restructuring going on and how it affected them. And it was really important that we have a vibrant engagement programme, so we used the opportunity to recruit Health Champions. Those were the main drivers for us.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 NHS Commissioning Support Staff, lay people and patients formed a volunteerbased NHS Change Day team. They went into shopping centres, supermarkets, hospitals, GP surgeries and on the streets to ask peoples opinions about the NHS. The event took place from 9am to 7pm on 13 March at 17 different locations across Warwickshire and Coventry.Leaders Everywhere The Story of NHS Change Day19 20. How they got involved: Anna Burns explained: Jackie Lynton (from the national NHS Change Day Team) asked us to consider getting involved. To be honest, NHS Change Day did not connect with us as an organisation in terms of making individual pledges. We are in a market town in a semirural area among a predominantly middle-aged white male group of GPs that 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 the commissioning process and the financial year starting on 1 April. If it hadnt been for Jackie reaching out, Im not sure we would have done it. Outcomes: The NHS Change Day team communicated to the CCG Governing Body that they should devise more opportunities for people to offer feedback to the NHS on the services they have received. As Anna Burns captured in her formal report on NHS Change Day to the CCG Governing Body: Face-to-face meetings are an important method of communication for people to raise concerns, and it is important that the feedback is recorded and acted upon. Work also needs to be done so that people know how to provide feedback, and to demonstrate that providing feedback makes a direct difference to improving services It is essential for the CCG to engage with the public and patients to ensure that their views are fed into decision making and to ensure transparency. In addition, the CCGs pledge allowed them to identify and recruit over 100 local Health Champions. Health Champions are invited to participate in the CCG by (1) receiving regular news and updates about what is happening in South Warwickshires health care services; (2) taking part in surveys and consultations to influence the development of services and how the CCG spends its money; (3) attending events, health seminars and other patient and public involvement activities; and (4) engaging other local people, patients and carers across the area. One in four people20surveyed on NHS Change Day agreed to participate in this programme, which accounts for one in ten of the presently enrolled Health Champions in the area. Lessons: In the context of the pledge itself, the local team received direct feedback about how to improve confidence in the NHS: reducing waiting times; weekend opening hours for GP practices (and/or access to get an appointment should be improved); better communication, including more information available in different languages; a helpdesk available for when service 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 offered feedback about NHS services. Of those that provided feedback, most did so face-to-face, with letter being the second most popular method of feedback, email the third most popular, and phone the fourth. The majority of respondents preferred not to be anonymous in their feedback. There were a variety of reasons for not offering feedback, including: not knowing how to provide it; thinking it would be a waste of time and not used or applied; being happy with the services and therefore no perceived need; or feeling decisions were already made. This taught the CCG that they should do more to let people know how to provide feedback and demonstrate it makes a direct difference to improving services. From a NHS Change Day perspective, the team felt the urgency of the moment. Between the Francis Report and upcoming changes to CCGs, there were many reasons to engage the public more broadly. The team will use this learning to develop future pledges in the real and present context of the moment when future Change Days occur.Leaders Everywhere The Story of NHS Change Day 21. Team members also valued forming relationships with the public face-toface, which also proved an effective strategy for recruiting a large number of Health Champions. Making personal connections allowed them to motivate members of the public to join the Health Champions programme. In turn, volunteers valued the opportunity to take on a public-facing role. Team leaders also built relationships with contacts from respective venues, and the CCG is likely to go back or has already been back to those places for further outreach. In addition, NHS Change Day provided an opportunity for senior leaders in the CCG (15 people) to work directly with GPs and registered nurses (22 people), as well as lay people and members of the public. As Directors, Anna Burns and Rebecca Davidson reported the benefit of spending time as a larger team and working toward a shared purpose. This kind of activity allowed them to build stronger relationships across hierarchical and organisational boundaries. Team members are now able to share ideas more readily and make better decisions together because they can call on shared experiences with one another that demonstrate their willingness to improve to the NHS. Changes in thinking and leading: Anna Burns reported, Because people are not inclined to give feedback, when they do, the ability to offer that feedback face-to-face is a really important mechanism. That was our biggest take-home message. We use social media and websites for outreach, but what is important is to talk to patients and the public faceto-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, we have to ask for it. It helps us to see how others see us; and it helps them to feel heard by us. Putting a response form on a website is insufficient. People want to talk.Leaders Everywhere The Story of NHS Change DayThe team has subsequently run campaigns and involved volunteers in direct outreach with the public. They also use press releases, Twitter, websites and other social media to build capacity around programmes like Health Champions. They feel it is good to communicate more often and more effectively with the public, especially face-to-face, and to invite the public to offer direct impact on the kind of care the CCG provides. NHS Change Day approach: As Anna Burns reported, Although we felt connected 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 wider NHS Change Day effort, but really this was about Change Day in Warwickshire and Coventry. Our people knew less about the national effort than they did about our local action. Our particular CCG has 15 staff. We are always asking them to improve things, that is our job. Change Day feels a little bit like a false concept, because we should be continuously improving and finding solutions every day to benefit patients. As a team we role model this behaviour, we do not accept mediocrity, we expect things to be better. NHS Change Day is a useful reminder to all of us that we cannot become complacent in what we are doing. Organisations who feel competent fail. If we are reminded to improve at improvement we will continue to try harder. I invited the GPs to join NHS Change Day and asked whether they wanted to do something in their own practices; no one wanted to do it. Some people feel differently [about this approach], and we have to accept those differences. Not that they dont get engaged they do in their own way! But we cant make people do things. We have to meet people where they are. They saw what we did. Next year they may feel that it is relevant to them. But it is not our job to impose it, just to encourage and support. That is the spirit of Change Day.21 22. We positioned our pledge to coincide with Change Day, but we were planning to do it anyway. We framed it that way among our CCGs and GP practices, so they knew that it was important to us, whether or not it was a part of Change Day. It was important to keep the pledge simple, to align it with what we were already doing. It had to be low-key, with a lowthreshold to be involved. We didnt spend extra money on it, we asked people for 3-hours of their time. We used resources we already had.intervention from a colleague, friend, compassionate health provider or care giver could make a real difference to saving lives.We might look at Change Day through a different lens. The fact that people said that it was so motivating to feel empowered to take action on one day, that signals that the rest of the time they dont. That is a much bigger problem for the NHS. NHS Change Day should be every day!In order to support the pledge, each individual or organisation had to commit to take some specific action that would spread the message of the U Can Cope campaign and direct individuals to resources that could help them if they were troubled by suicidal thoughts. We had to be sure that it was not just a paper exercise, explains Alys Cole-King. In practice this meant that every supporting organisation had to communicate the U Can Cope message to their members, supporters or staff.2.2 The Story of Open Minds Alliance Community Interest Company The pledge: I pledge to share we can all get through distress and suicidal thoughts. There is always help/hope via U Can Cope www.connectingwithpeople.org. This pledge was posted on 8 March, one week before NHS Change Day, with thousands of actions taking place over the following weeks. The pledge was supported by a team led by Alys Cole King, a Consultant Liaison Psychiatrist, together with the Open Minds Alliance Community Interest Company, based in London and North Wales. Open Minds Alliance CIC was established in 2010 and provides suicide prevention training and resources aimed not just at medical professionals but society as a whole. As Alys Cole-King and Gavin Peake-Jones explain, our belief is that emotional distress, and tragically, suicide still affects and takes far too many lives. We felt that responsibility for people with suicidal thoughts was seen to lie with specialist mental health services and others were more nervous to get involved. However we knew that early22From the outset the objective for Open Minds Alliance CIC was to secure as many supporters of the pledge as possible. The pledge was deliberately crafted so that it would appear in a single tweet the aim being to secure as many re-tweets as possible.Why this pledge: For Open Minds Alliance CIC, participating in NHS Change Day was about much more than a publicity or marketing drive. Their approach to suicide prevention is built on a belief that it is possible to develop the protective factors of each individual and help them to gain knowledge and control over suicidal thoughts and impulses. Alys Cole-King describes this as, a compassionate alternative to the so-called management of suicide riskit promotes a role for all, and recognizes that each encounter with an individual with suicidal thoughts is an opportunity to intervene and potentially save a life. When she talks about promoting a role for all, she really does mean all: the resources made available by Open Minds Alliance CIC are intended to be used by everyone and anyone. How Open Minds Alliance CIC got involved: Alys Cole-King has been working collaboratively for many years on the issue of suicide preventionLeaders Everywhere The Story of NHS Change Day 23. and has a wide range of national contacts. One of these contacts, Kath Evans, is Head of Patient Experience for NHS England and has worked closely with a number of the NHS Change Day Core Team. When Kath heard about NHS Change Day she immediately thought of Alys and the work of the Open Minds Alliance. Kath knew Alys and her colleagues were looking for a way to effectively engage the wider NHS and might be attracted by the possibilities offered by Change Day. So she got on the phone 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 Minds Alliance CIC team point out this is an especially remarkable achievement given the social stigma associated with suicide. Change Day had an amplifying effect, explains Gavin Peake-Jones. It enabled us to get to a much wider range of people. It has been a catalyst to broaden thinking about suicide and has enabled us to have impact at all the different touch points. By breaking down stigma, people will get the support and resources that they need. Open Minds Alliance CIC was notably successful in securing the support of a number of large organisations both inside and outside the NHS. These included The Royal College of Psychiatrists, The Professional Cricketers Association and The Rugby Players Association all of whom committed to take action. In the case of the Betsi Cadwaladr Health Board, where Cole-King is Consultant Liaison Psychiatrist, this included handing out leaflets to staff and patients, two direct emails to all staff and coverage in internal newsletters. It was absolutely unprecedented, reflects Cole-King. Other supporters included the College of Emergency Medicine, which communicated the U Can Cope message to all its members via its newsletter and Twitter and Barnsley Metropolitan Borough Council which put a mailshot through every home in their locality.Leaders Everywhere The Story of NHS Change DayFrom their own research, Open Minds Alliance CIC knew that people who are in distress tend to be seen first in primary care and that there is a deficit of training and resources in that area. As a result of contacts made and supporters recruited through NHS Change Day, new work in this area has begun, for example in Dudley & Walsall where Open Minds Alliance CIC is working across mental health teams and their partners. The overall success of NHS Change Day has provided an additional and unexpected impact for the work of Open Minds Alliances partners. Being part of Change Day provided a greater level of credibility for our work, says Kirsty Thomson, Head of Fundraising at Awyr Las Gogledd Cymru a funder and close partner of Open Minds Alliance CIC. To be able to talk to future supporters and to speak to our bosses about the impact of the work their ears pricked up when they heard it had been part of NHS Change Day. Lessons: Open Minds Alliance CIC is located in North Wales and Alys Cole-King is based at Health Board within the Welsh NHS (not the English NHS). While Open Minds Alliance CIC works extensively with the NHS in England, the Welsh teams distance from London is one reason why the advantages of being part of a single day of action stand out for the team. The national platform brings a heightened level of awareness and provides a focus, says Gavin Peake-Jones. Change Day is something you cant avoid. According to Kirsty Thomson there was also value in participating alongside others: Seeing that there is a national Change Day was inspiring. Understanding that its not just people on the periphery who want to make change happen but people throughout the NHS. There was a sense of solidarity of not being on your own. Feeling part of something bigger is a really important factor.23 24. NHS Change Day approach: Alongside the focus and solidarity created by a single day of action, the team at Open Minds Alliance CIC was also struck by the way in which Change Day gave permission for people to initiate and embed change. The national day was symbolic giving people the time and space to think about the change they would like to make.universally adopted within the NHS. Im an enthusiastic user of Twitter, says Alice Cole-King, which led to raised eyebrows from some colleagues! One of the successes of Change Day was that it inspired people who may not normally engage in social media. It showed how it can enable individual nurses, physios frontline staff to collaborate.In addition the structure of Change Day itself reflected a different approach to culture and organisational change that resonated strongly with the approach of Open Minds Alliance CIC: The way in which NHS Change Day was formulated people identified issues for themselves and others could sign up or not meant that it was self-selecting. What came up were the issues that mattered to people. (Sian Peake-Jones) In the same breath as talking about the change we were also talking about being part of Change Day. It allows people to get on with things and breaks down barriers. (Gavin Peake-Jones)In addition the team itself valued the changes in their own thinking prompted by their interactions with a whole new set of contacts as a result of Change Day: Weve had people asking us challenging questions and asking us to do things slightly differently. NHS Change Day has been a catalyst to broaden our thinking.Although he now gives much of his time to Open Minds Alliance CIC, Gavin Peake-Jones has a professional background in organisational change having worked for the likes of Marks & Spencer and Ford as well as founding a successful social enterprise. He saw NHS Change Day as a rare example of a large organisation demonstrating that it understood the complexity of the change process rather than seeing the organisation as a machine with inputs and outputs. For Peake-Jones, working with people at the grassroots to set strategy is critical. This was one of the strengths of Change Day as it enabled a flow of ideas between the people who were pledging. In this way Change Day created the right systems and processes to enable the change to take place.It is perhaps not surprising that Open Minds Alliance CIC was able to make such good use of the opportunities of NHS Change Day. After all, as Gavin Peake-Jones says, there is a campaigning quality to our work. Were passionate about embedding change. We want to be that change. Its not a routine job for any of us. Or as Alys King-Cole concludes, Its also a very enjoyable activity. These are the things that motivate us when we go to work making a difference for people.Changes in thinking and leading: Open Minds Alliance CIC recognise that as innovators they have tended to work in ways that are not24Gavin Peake-Jones reflected that Change Day had the effect of generating new points of leadership in the NHS, of which Open Minds Alliance CIC was just one: Change Day is a national initiative that gives us permission to initiate culture change.2.3 The Story of Derbyshire Community Health Services Trust The pledge: The staff of the Derbyshire Community Health Services (DCHS) Trust made a corporate pledge to identify and support Innovation Scouts through a local NHS Change Week. Individual and team pledges included pledges on Change Day and Change Week and some are ongoing today.Leaders Everywhere The Story of NHS Change Day 25. The corporate energy for the pledge came from the Service Improvement team who secured a Board commitment to support a Change Week to coincide with Change Day. Led by Ian Murray (Head of Service Improvement & Innovation), Donna Clemens and Helen Short (Service Improvement Managers), the Service Improvement team communicated directly with the 200 voluntary Innovation Scouts asking them to make personal pledges for NHS Change Day and to recruit others in their part of the organisation to do the same: the Improvement Leadership Training they had all taken was voluntary so we already knew they were passionate and engaged about improvement and creative thinking. We knew most of them 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 which included email invitations to all staff to join in Change Day and Change Week. The comms team was great! We had a 10-day count down with daily emails including the Change Day branding asking what are you going to do to make a difference? and we highlighted the pledges that the Chief Exec and other members of the Exec Team were making. As part of the PR strategy the Service Improvement team developed a menu of pledges which they encouraged staff to adapt, adopt or use as a prompt for their own thinking. The Service Improvement team was keen to ensure that Change Day and Change Week fast-forwarded change in a sustainable way. They launched the My Idea email address as part of the Change Day/Change Week campaign and most of the DCHS pledges were made using this route. This meant that all the pledges came through to a single point in the Service Improvement team: It was important to understand who was making pledges and where they were in the organisation. It meant that we were able to provide support and enable corporate pick-up where appropriate.Leaders Everywhere The Story of NHS Change DayThe team created a local pledge wall and all the DCHS pledges were uploaded to the national NHS Change Day website. One Innovation Scout on each of the Trusts sites volunteered to raise awareness of Change Day and to promote it amongst teams. During Change Week they were asked to make themselves as visible as possible to encourage people to make pledges. Why this pledge: DCHS has taken a proactive approach to supporting innovation for a number of years. A survey identified that staff often didnt know where to go or what to do with their ideas for innovation and change. DCHS therefore developed an innovation infrastructure which included identifying volunteer Innovation Scouts who were provided with Improvement Leadership Training. Innovation Scouts came from all parts and levels of the Trust and so could act as the eyes and ears of the organisation if staff came up with an idea they would be the first point of call. The Service Improvement team had aspirations to go further. They wanted to make it as easy as possible for members of staff to share their ideas and get the support they needed to make them a reality. The Service Improvement team therefore planned to launch a dedicated My idea email address with a commitment that each email would receive a response within three days including a short plan setting out the support they could provide. Change Day seemed like an ideal catalyst and was a driver to publicise and fast-track some of the things that we were already thinking about. We brought things forward because Change Day created a deadline. We thought lets get it done for Change Week so that we can promote a full end-to-end model that people can have confidence in.25 26. How DCHS got involved: Members of the Service Improvement team responded to early adverts for NHS Change Day and brought it back to the team and organisation. The team saw NHS Change Day as an exciting opportunity to motivate and engage staff in innovation and change. In particular the team viewed NHS Change Day as a way to mobilise and motivate the 200 Innovation Scouts already developed within DCHS and to to get them to influence harder to reach groups. Outcomes: In total over 500 teams and individuals made over 150 different pledges: Big themes appeared around talking and listening more; with patients and with staff. Seeing things from different angles and perspectives to ensure we are managing our staff in the best way and delivering care in the way our patients want. This has lead us to having a drop-in at our AGM where we will be asking patients about the best way to communicatewhat they think about our services which isnt necessarily a complaint or a compliment, this could simply be small things they think could make a difference. The Harlem Shake: DCHS Healthy Work Champions in the Health Records Team at St Oswalds Community Hospital pledged to be active in our workplace as part of our health and wellbeing. During Change Week they ran a range of drop-in activity sessions for staff which ranged from yoga to Nordic walking. To promote this pledge and encourage participation in the sessions they made a video of themselves doing the Harlem Shake which they posted and which became a local sensation with over 2000 hits. Not only did this help to bring 100 people to the sessions it also helped to create a buzz around Change Day in DCHS. All in all this was definitely worth doing and worth all our hard work and effort, and from the feedback we have received from staff they all really enjoyed it, and were very grateful to us for giving them the opportunity to get26involved, look at new things, and really take a look at themselves (which we dont very often have time to do), Nicola Shaw, Medical Secretary. Podiatry Services: Danny Connor, Podiatry Manager, pledged to obtain patient questions via video and play at team meetings to discuss feedback and communications to patients/service users as a way of enabling patients to tell their own story, in their own words, in their own way. Staff reported that sharing the experience of patients in this way brought patients into the room ensuring that patients remain at the heart of what we do. As a direct result of video shot during NHS Change Week there have been improvements in signage, patient information and notification. The team now embraces this way of capturing the patient experience: video items have become a regular feature of agendas and videos are shown quarterly at team meetings. Video replies from the Podiatry Manager responding to patients ideas, observations and questions are also provided to present a face to the public (as opposed to the faceless management!) There are now plans to roll out this approach to capturing patient experience across DCHS. DCHS is also looking at other ways to develop this pledge such as filming staff with questions for governors and managers to be discussed at leadership and staff forums. The ongoing impact of Change Day can still be felt at DCHS: Weve got initiatives that have happened and are continuing as a result of Change Day. It allowed a bigger footprint of opportunity within the organisation to have permission to make a difference. It allowed people to channel ideas through a framework. Before, they might have been lost or forgotten before they had been able to grow. People now know where to go for support and we can help nurture them.Leaders Everywhere The Story of NHS Change Day 27. The Service Improvement team have been continuing to support many of the Change Day pledges through their Lets Keep it Going programme. This has included visiting teams and individuals who made pledges to discuss sustainability and to identify barriers and blockages. Change Day has become part of the improvement and innovation landscape at DCHS: We keep talking about Change Day and feature it in our Trust comms flyer to celebrate what weve achieved. The Chief Exec mentions it in emails. The scene is being set for next year! Lessons: The amount of effort that went into putting an effective PR campaign together beforehand. We are a big organisation with over 4500 staff. Getting the message over in as many different ways as possible was fundamental to making sure that people got involved. We needed to make it as easy as possible for people to pledge e.g. having the menu of pledges to sow the seeds which really increased take up. When we first heard about Change Day we thought it was a brilliant idea 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 improvement and change at scale? So we had to think about how we could make sure that it wasnt just one day without any measurable impact. Having the pledges channelled locally meant they could be followed up after Change Day and in some cases developed from local to corporate pledges.Where there is something a bit different you start with the people who are most committed and then you get some momentum which brings the uncommitted and then even the most resistant. Changes in thinking and leading: We seem to be coming out of a culture where weve found weve had to overtly give permission for staff to make a difference. In our Improvement Leadership Programme we say if you need it this is the permission to make a difference and people say oh, right, OK. We didnt know we could do that. NHS Change Day did that too. For the NHS, Change Day was a little bit different. To bring it into the NHS had some foresight. But it was simple it didnt require complex mobilisation; you could think about your pledge on the day and then carry it out. You can make a simple pledge that will make a difference to a single 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 dont. It helped to bring you back to basics. It influenced the approach of managers and showed them the skill and creativity they have in their teams. It demonstrated that people at the front of their teams know their business better than others e.g. the managerial support for the Healthy Working initiatives I dont think that would have happened before.It remained entirely voluntary the spirit about it is wanting to make a team or an individual difference. I truly believe that for service improvement one volunteer is better than 10 pressed men.Leaders Everywhere The Story of NHS Change Day27 28. 2.4 The Story of Steve Fairman, NHS England The pledge: Steve Fairman, the Director of Business, Improvement and Research for NHS England, pledged to spend a day shadowing a GP, James Gray, in Sheffield; and he asked James for a reciprocal pledge to shadow Steve for a day. Steve spent a day in June with over 100 patients who came into contact with members of James Grays general practice team. Throughout the day, Steve shadowed two receptionists, a GP responsible for telephone triage, a GP conducting home visits, and a GP doing in-patient surgery. He also shadowed the practice manager. I saw all ends of the spectrum in a single day. GP James Gray and practice manager Joanne Marshall now plan to shadow Steve for a day. I dont want to make it easy for them; they are going to get the nitty-gritty. They will be here when I have corporate decision-making work. They are going to see that I spend a lot of time video-conferencing because I cant be in two places at once, and that is what a national job demands. It is a very different way of working than on the frontlines.Outcomes: People have asked me: What was the point of my day in Sheffield? What has changed as a result? For me, my attitude has changed. But I cant show you that on a graph or a run chart. It will manifest its impact because other people hear what I say or because I develop a relationship in a different way or because I argue a point more persuasively by drawing on my experience. Some people need numbers to understand change. I started my career in information management, and I appreciate the numbers. But Ive moved on from that. I lead a lot of leadership development programmes for the NHS, and my pledge has armed me with real life examples. I used to put up PowerPoint slides with data and evidence and walk through them. Now I put up the same slides and call on my experiences with GPs and patients to illustrate why a particular idea is importantWhy this pledge: Although Steve had been aware of NHS Change Day for months, he had not committed to a pledge that was meaningful to him until a few weeks before Change Day. Over the years as my career developed I got further and further from patients. I wanted to do something that would engage me with the patients and also provide a reciprocal lens for someone else to see what it was like at my end of the NHS.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 and found 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 the television and asked James whether he watches Embarrassing Bodies (the TV show). James said no. Mr. Jones said, Well, I have exactly what the guy on last weeks show had, and I know exactly what needs to be done about it. I saw how Mr. Jones expectations affected his encounter with James, their relationship and the care he received. I realised how hard the work of the GP is in dealing with those kinds of expectations before an exam has been completed.How Steve got involved: Steve was first exposed to NHS Change Day through his work with Helen Bevan on the Change Model and was a part of the NHS Change Day Expert Oversight Group.I also tell people about Mr. Smith. While I was sitting with another GP between surgery appointments, the phone rang from reception. Mr. Smith is here, can you see him? The GP said yes, send him in. Mr. Smith did not have28Leaders Everywhere The Story of NHS Change Day 29. an appointment. He was in his early 80s and had dementia. The practice agreed that they would care for him even when he turned up on the wrong day to see his doctors. They agreed that whoever had space would find time to see him. They also agreed with Mr. Smiths daughter that they would write any instructions for care on a brightly coloured card and put it in his top pocket. She agreed that she would look for the cards and follow the instructions. On this day, Mr. Smith needed long socks and cream for a sore on his leg. I tell this story to demonstrate what a dementia-friendly practice looks like.I am involved in a piece of work to identify research priorities from clinical groups across the country, and I have asked two GPs from Sheffield to take part because I want their views to be heard. They believe they can do things in primary care that are currently being done in secondary care. Initial studies suggest that they are right.Lessons: I was surprised at how profound an impact my pledge had on me. I didnt expect to learn many of the things that I encountered. For example, I learned about the sometimes directly conflicting incentives of ownership in GP practices. GPs are partners in small businesses. They all have a vote, and unless they all agree to something within their group, the practice as a whole cannot change.I now seek out this kind of thing. For example, I work with a graduate trainee. Usually she comes to my office, and we discuss issues pertaining to where she works, the people she works with. I decided to take the train to London to visit her at her hospital. Now I understand who her people are and what her building looks like, and I can empathize when she tells a story. It is important not only to her training, but to the outcome of our relationship that I made this effort to understand her experience.This [approach] has potential to create a significant, even if not always intentional, blockage to improvement.... There is a tension in having the incentives 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 for developing transformational healthcare change programmes at a national level. He has a varied background extending from academic social research to health economics to demographic forecasting. He is also responsible for helping develop a better evidence base to inform future NHS-wide decisions. In Steves words: Now that I know more about what happens at the frontlines, I ask myself: What are the gaps in knowledge that frontline practitioners would find helpful if they could commission research on it?Leaders Everywhere The Story of NHS Change DayMy team needs to bring this kind of credibility to our work. It comes from understanding what people at the front lines are doing and the issues they are facing.NHS Change Day approach: Change Day is a very important part of the NHS. If we all have tools for change in our tool bags, as it were, Change Day is a very important tool. Its not a tool that everyone will want to use. I asked my own team to make pledges, and not all of them did. I understand; its not how most people in the NHS think change happens. I have many traditionalthinking people on my team. Change Day is not their thing. They would rather do some lean thinking down the corridor. But Change Day is about doing something differently. Its not an expert telling you the best way to change; its not a consultant working with you to create change. Its about people seeing things from their standpoint and saying: I am going to change that.29 30. Whizz Kidds featured on NHS Change Day at Healthcare Expo I was so pleased that it came from the bottom up way of thinking about change. Change Day empowers individuals in the NHS and there are an awful 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 are making a powerful statement that the NHS needs to change. Half a million people can spread the word about Change Day to everyone they go home to. One of the potential sources of Change Days power is that it is building a base for change.30I have noticed that the reports about Change Day highlight numbers: how many people did this, how many Tweets, how many pledges, how many organisations, how many chief executives. Are they responding to the critics who want to see measurement, metrics, impact? I dont know. But it leaves out the bigger lesson that we can learn from Change Day. It is about leadership.Leaders Everywhere The Story of NHS Change Day 31. 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 without firm data showing the link between Change Day and an improvement in patient care or specific cost saving, it is not possible to call Change Day a success. It is certainly true that while there are many examples of specific improvements detailed in this report and associated case studies, NHS Change Day 2013 was not designed in a way that would allow measurement against traditional improvement metrics. The appropriate place for traditional improvements metrics to emerge within Change Day is at the level of pledge-makers, and it is thereby a voluntary activity as part of a pledge. Those involved in the design of NHS Change Day 2013 do not shy away from this criticism and readily admit that if you want evidence of direct patient change that is sustained I suspect there is not a lot (Damian Roland). This very issue was debated among the core leadership early on, and they intentionally pursued a strategy that gives people the option to choose the nature of their pledge, instead of signing onto one or two specific pledges that would take on the quality of a national campaign (and measured more traditionally). Thus the number of pledges alone is not so much evidence of change but the impact of reach in using social media. The Change Day leadership team sees the emphasis on pledging instead of acting on a pledge as an area for improvement. It is one thing to pledge, it is another in terms of what difference it made,points out Helen Bevan. We dont have conversion rates. What percentage of pledges made converted to3action? When you talk to people in the voluntary sector, they have a conversion rate for pledge-based campaigns. The fact that so many people pledged was important, but we have to understand a lot more about what impact it had for patients and the system as a whole. The core team has been examining the patterns in the 2013 pledges in order to develop metrics for 2014. They recognize that many more elements of Change Day can be measured, such as impact measures from pledges or on the effects of pledges on involved patients and staff. For example, since many pledges in 2013 suggested that participation arose from a commitment to the values of the NHS, and that involvement was intrinsically motivating, Change Day 2014 could assess whether Change Day contributes to motivating staff in their jobs. It might also be helpful to measure the impact of pledges on organisations in the system. For example, Hertfordshire Community Health Service Trust used Change Day as an opportunity to bring together clinicians from across their system to review the paperwork that they are required to complete, resulting in significant changes to the entire reporting system. In addition, Change Day 2014 can track the conversion rate of pledges into actions.3 Beyond impact measures, developing metrics that reflect the unique character of NHS Change Day is both possible and desirable: NHS Change Day 2014 can embrace its unique design by quantifying how it works. For instance, it is important to count how many pledges came from frontline staff and patients, as well as senior leaders as an indicator of the effect on distributed leadership.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 as a result?Leaders Everywhere The Story of NHS Change Day31 32. Core leadership team members on NHS Change Day Measuring how many people told an online or on-the-ground narrative to mobilise others as part of their pledge would provide evidence of the level of new capacity developed through NHS Change Day. Similarly, counting how many new relationships were built through Change Day is an important indicator of success. Quantifying the design elements of the Change Day approach helps tells the story of how it enables distributed leadership, commitment, and boundarycrossing relationships to innovate around patient care and contribute to other ongoing organisational challenges.32Measuring the impact of specific pledges and collecting evidence around the outcomes of the Change Day design cannot be understated. But despite the prevailing culture of evidence-based activity in the NHS, an absence of impact measures is not in itself an indication of the success or failure of NHS Change Day 2013. Change Day did not set out to be a traditional improvement programme. On the contrary, it was deliberately designed to be something new; a movement of people within the NHS motivated by shared values and a commitment to the possibility of change and improvement. As one leading participant puts it: For this sort of thing I think it would be counterproductive to try to measure the direct impact of the interventions (James Haddow). Another adds: The greatest successLeaders Everywhere The Story of NHS Change Day 33. we had was getting people involved in something that just wouldnt have been possible a decade ago, five years ago maybe even two years ago (Damian Roland).3.2 Design: NHS Change Day, Social Movements and Hierarchyfrontlines to take action while at the same time engaging hierarchical leaders. In their own words the NHS core team sought to make the best of both networks and hierarchies, working through informal networks and communities of interest and creating a genuine grassroots movement at the 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 at an early stage. I sought the support of Jane Cummings, Bruce Keogh, David Nicholson and Miles Ayling, who were all massive supporters but respected the grassroots nature of Change Day.NHS Change Day did not emerge from nowhere. For over ten years a number of leaders in the NHS have been laying the groundwork for the development of a social movement principles to improving health care. This included engaging with and adapting insights from social movement theory and research, developing skills used in community organising and developing a Call to Action framework used to mobilise action on critical challenges (Bate, Bevan and Robert, 2006; NHS Institute for Innovation and Improvement, 2011). This activity led to success but on a small scale; the next challenge was to deliver change across a whole system.The innovative design of Change Day resulted in a particular set of outcomes (as opp