Measurement for Improvement

You might be undertaking a project to improve an aspect of the service you provide and are being challenged to demonstrate the impact. How can you do this? Or maybe your current performance report is more confusing than enlightening and you spend a lot of time in meetings arguing the toss. How can you really know whether things are getting worse or better?

Both those scenarios revolve around the issue of measuring something. And even if we are happy to tackle this, and let’s be honest most of us would rather not, we run into a number of problems. Any one of these problems can prevent us from being able to answer those questions. And this is why a few of us at the NHS Institute for Innovation and Improvement created a short video to point out these problems and suggest how they can be avoided. You can view the video here 1.

The first problem we face is that everyone has a different view as to what we are measuring and why. Leif Solberg 2 and colleagues wrote a super paper back in 1997 that addressed this. They said that there were 3 basic reasons why we measure: for accountability; for research and for improvement. And each of those has a distinctive approach which we need to heed. We are thinking in this article about knowing whether we are getter better or not, this is measurement for improvement. Those who come from one of the other perspectives can struggle to make the shift. For example those who inhabit the world of performance and targets (accountability in Solberg’s language) sometimes don’t pay enough attention to the way data is collected. Those who come from a research background can struggle with the absence of their favourite statistical tests. Neither group can be comfortable with the idea of plotting data over time.

So why are we wanting to measure? What is it that we want to know exactly? Stacey Barr who writes on performance measurement has a great blog post 3 on just this. We need to be very specific about what we want to achieve, using plain simple English and not resort to ‘jargon’ phrases such as ‘best quality’. One of the main reasons why project outcomes are so hard to measure is that they are not expressed in a way that makes them amenable to measurement. Follow Stacey’s advice and this problem is solvable. She also has lots to say on the other problems we’ll cover too so have a browse on her website.

Once we’ve sorted that out we can move onto the next problem which is choosing the right things to measure. If we’ve followed Stacey’s advice above we may already have that one covered. If we have phrased our aim as an outcome, the most relevant measure will be an outcome measure. But as Donabedian reminds us in his Quality Model 4 to get a good outcome you need to consider both the inputs and also the processes by which care is delivered. So how are we doing on those? Tracking both inputs and process compliance could be useful things to do. Finally, we work in a health and social care system so we always have to be mindful that any changes we make could have a knock-on effect elsewhere. Identifying and tracking potential adverse effects, a ‘balancing’ measure, is the final type of measure we should consider.

At this point some would think that we’ve reached the end of our problems. After all, we know what we want to measure now so let’s just ask for the data and away we go. But both defining and collecting data can contain traps for the unwary. Neil Pettinger discusses some of the pitfalls about definitions in his blog 5 on measuring bed occupancy and Davis Balestracci reminds us in another post 6 that measurement itself is a process and we need to be careful how we go about it.

So take some time to ensure you have common agreement on definitions. And test the data collection process you are using. Don’t assume any process will work perfectly first time. The first data we should collect will give us an idea of where we are now. This is our baseline and we judge the impact of the changes we have made against this position. This means of course that we have to start collecting our data before we make changes. It sounds so obvious that you are probably thinking why have I mentioned it. Sadly many projects suffer because enthusiastic staff have rushed to make a change without knowing how they are doing now. Of course it is not always possible to obtain baseline data, for example if you are starting a new service, but you should make a determined effort to do so.

When we do display data about our performance, it will show variation. How do we handle this? Most of the time we try to remove it. After all that’s what using totals or averages do for us, they ‘clean up’ our data and get rid of all that messy variation. However this can be dangerous. Many years ago Dr Walter Shewhart (creator of the SPC chart) coined 2 rules for presentation. They are:

Rule One: Data should always be presented in a way that preserves the evidence in the data

Rule Two: When an average, standard deviation or histogram is used to summarize data, the user should not be misled into taking action they would not take if the data were presented in a time series

If I were to paraphrase Shewhart’s rules I’d say “Don’t use 2 point comparisons or averages on their own”. Shewhart was concerned to ensure that the ‘messy’ variation we want to airbrush out stayed in full view. Why? Because it tells us a lot about how the process we are measuring typically performs. And we can use that knowledge to help us make it a better process.

So how should we present time series data? This is where run charts and Statistical Process Control (SPC) charts come in. Run charts are simple to use and anyone can create them. Just follow the guidance in this article 7 to get started. SPC charts appear more complex (they have 2 extra lines) but are no more difficult to use once you understand how they are constructed. The best reference on these is a book called Understanding Variation 8 by Don Wheeler.

So now we have addressed our problems, the final step is to make a decision based on the information in front of us. And, if we really have chosen our measures well and obtained good data, that’s simply not a problem! The rules or tests associated with run or SPC charts will guide us to whether we have just random variation in our data or whether there are specific (or ‘special’) causes lurking in there as well. That knowledge drives the type of decision we make. We can find and address special causes with a specific contingency plan. For unacceptable random (‘common cause’) variation we need to think about revising or redesigning the whole process.

If you’ve been counting up the problems or steps mentioned in this article so far, you will have got to six. And there are seven steps to measurement in the video referenced earlier. So what’s the seventh? It’s simply this. Keep going. Don’t think that because you’ve studied your data once and made some decisions, you can now forget all about it. Continue to collect, plot and review your data on a regular basis. Once you get into the swing, you’ll find that won’t be a problem either.

Mike Davidge, Director, NHS Elect









7 “The run chart: a simple analytical tool for learning from variation in healthcare processes”; Perla R, Provost L, Murray S; BMJ Qual Saf 2011;20:46e51. doi:10.1136/bmjqs.2009.037895

8 “Understanding variation” by Don Wheeler obtainable via

How Emotional Intelligence Became a Key Leadership Skill

Do you ever get the feeling that you need to learn more about emotional intelligence? Curious as to whether or not integrating the rational and emotional sides of yourself will improve your leadership skills? This article from the Harvard Business Review looks at the history of research in emotional intelligence and developments in the five key areas of self-awareness, self-regulation, motivation (beyond money and status), empathy, and social skills such as managing relationships and building networks. Daniel Goleman claims that emotional intelligence is the sine qua non of leadership and I’m inclined to agree with him; leadership focuses not just on results but also relationships. If we can build the skills and resilience to have better relationships with ourselves and others then better results will surely follow.

oliandersonOli Anderson @OliJAnderson

Oli is a mental health worker currently based in Bradford, West Yorkshire. He is currently studying for a coaching diploma and has just finished his first book, Personal Revolutions, a work of practical philosophy. He has been on dialysis since 2007 and is currently waiting for a kidney transplant.

‘Every light was a story’: learning from stories of experience

In this piece I will explore the use of stories and, in particular, digital stories, as ‘objects of reflection’. The intentional creation and collection of stories can prompt new ways of thinking and highlight potential and actual solutions. If we are prepared to listen and attend to these stories, there are powerful lessons for change and improvement.

In her novel Lighthousekeeping, Jeanette Winterson likens stories to flashes of light from a lighthouse: ‘Every light was a story and the flashes themselves were the stories going out over the waves, as markers and guides, comfort and warning.’

Over the past 12 years I have had the great privilege of working with nearly 1000 people who have participated in the Patient Voices Programme, sharing their stories of care (and sometimes the lack of it) with the aspiration of improving the quality and safety of care for everyone: patients, service users, carers and the clinicians who provide clinical care for them. Every story has been a flash of light and every one offers us an important opportunity to learn, to reflect and to do things differently.

But let us, for a moment, go back in time.

At the beginning of the 21st century, stories were not considered worthy of inclusion in the various methods designed to improve the quality and safety of care. Evidence Based Medicine had, quite rightly, grown in importance and influence in the world of healthcare; stories were considered to be at the bottom of the hierarchy of evidence. In fact, in those long-ago days, patient experience was only just beginning to be recognised as being of importance in understanding how to improve the quality and safety of everyone.

But times have changed and now stories are everywhere – and everyone is talking about them!

So what has happened to bring about this change? Why are stories so important?

The French philosopher Pascal is alleged to have said: ‘We tell stories to entertain and to teach.’

If you think back to your best teachers, I would guess that they were also good storytellers. For those of us who studied humanities, stories were at the core of our learning: learning about humanity from the stories of literature and history. The best teachers were those who could tell the best stories. The author Jeanette Winterson tells us that ‘Stories are always true – it’s the facts that mislead’, reminding us that, at the core of every good story is something important about the human condition. Those of us who are engaged with the crucial work of transforming health and social care would do well to attend to her wise words.

But there is more to stories than just learning about humanity, although that is a great starting point. Stories offer us the opportunity to suspend belief – or disbelief – to wonder and to wander, exploring possibilities that might never otherwise present themselves. In his excellent book If this is your land, where are your stories, Chamberlin encourages us to ‘find the common ground’ that stories invite us to share. He encourages us to ‘understand our stories because our lives depend upon it.’ When we hear the opening words of a story, we can enter a different state, one that allows us to hold ambivalence, to suspend judgement, to wonder….

Wonder and wondering are closely related, and stories teach us that we cannot choose between them. If we try, we end with the kind of amazement that is satisfied with the first explanation, or the kind of curiosity that is incapable of genuine surprise. Stories make the world more real, more rational, by bringing us closer to the irrational mystery at its centre. Why did my friend get sick and die? Why is there so much suffering in the world? Whose land is this we live on? How much is enough?’ These are crucial questions for all of us, but especially those of us who are concerned with driving change in health and social care.

The great guru of reflection, Donald Schön, tells us that Storytelling is the mode of description best suited to transformation in new situations of action.’ This is an important message for us as change agents. Time and time again I have seen the process of storytelling and the product – the stories – bring about transformation.

The first, most radical and, undoubtedly, the most important changes resulting from the story are the internal changes within each storyteller, reinforcing the idea that change begins with me. I am not statistically valid. So I can’t change the world with my statistic, but I have the opportunity to change the world with my story.

In most cases, telling an authentic story has an enormously beneficial and healing effect, often freeing the storyteller to move forward in new ways.

Tim was a roofer. It was his last call of the day – an urgent call to repair storm damage to a wet factory roof. The roof was slippery. Tim fell 50 feet to the concrete floor below. He tells of the long journey back to life and reality, the struggle with pain, depression and PTSD.

Having created a digital story about his experiences, his comment was ‘I can now put this DVD on the shelf. I’m finished with that story and now I can move on.’ A year later, he made a very different story. Tim’s first story can be seen here. His story, and others from that project, are used by Sheffield City Council to promote greater understanding and awareness of the needs of people affected by mental health problems and those who care for them, helping the Council understand the kind of support that will be most useful and appropriate.

Stories can also bring about organisational change.

A Nursing Times article about the use of storytelling to engage teams suggests that space and time to share stories at work can help team members understand one another better, feel valued and share values in a way that honours each individual but also nourishes the team.

Offering teams the opportunity to tell and share stories has been helpful for one clinical team who had been placed on special measures. Three years on, things had improved immeasurably with a new ward manager, but there were still unresolved feelings. An opportunity to tell stories resulted in shared understanding and renewed enthusiasm for their shared work on a busy oncology ward.

After the workshop, the team manager commented that there was better team working and more obvious enthusiasm for the work. The stories can be seen here.

Digital storytelling work has been ongoing with Manchester Mental Health and Social Care Trust since 2011. The work was commissioned in an attempt to address poor ratings in both patient and staff satisfaction surveys.

Two years later, 43 stories had been created. Staff and patient satisfaction rates had improved dramatically, the number of complaints has been reduced by 45%, litigation costs had dropped by 50% and a great deal of management time was being saved.

One story is shown at the beginning of every Board meeting. Important lessons are drawn from the stories, the Board given an opportunity to challenge and the Board then undertakes to assure itself that undesirable things could not happen again and that good practice will continue. The Chief Executive of the Trust blogged about the impact of one of the stories here.

Stories are used in staff training and induction as well as in recruitment interviews to ensure that new employees will have an acceptable level of emotional intelligence and will share the Trust’s values. The use of stories in recruitment has changed the approach of the Trust towards its staff – you can read more about that here.

A good story isn’t just a story, you see. It is an opportunity for reflection and for transformation.

What stories do you need to hear?

What stories do you need to tell?

How will you tell them?



Emotional Intelligence

Emotional Intelligence

“No one cares how much you know, until they know how much you care.”
Theodore Roosevelt

The theme of this edition of The Edge is ‘people’. Our inspiration came from the  Maaori whakatauki (proverb) which you can see in the editorial. Emotional intelligence provides a way to empathise, coach and celebrate the unique potential that people have.

It is around 19 years since I first read the seminal book on ‘Emotional Intelligence – Why It Can Matter More Than IQ’, written by Daniel Goleman, and it has been my ‘go to’ book ever since. The effect on me was profound. Like many others in health care, I had been focusing on gaining technical skills: clinical skills, managerial skills such as business planning and, as I moved into the world of improvement and innovation, expertise in relevant tools and methods. While Goleman confirms that all of these skills are important, he describes them as “entry-level requirements” and argues that leaders with emotional intelligence are more effective than those without.

Goleman (1996) describes emotional intelligence as a group of five skills:
Self awareness – knowing your own strengths, weaknesses, values, your own emotional state and your impact on others.
Self regulation – your ability to control any disruptive impulses or moods, suspend judgement and think before acting.
Motivation – optimism and a passion to achieve for the good of a situation rather than, for example, rewards of finance or status.
Empathy – an ability to understand the emotional make up of others and a skill in being able to work with people by responding positively to their emotional reactions.
Social skills – building rapport, excellence in developing relationships and networks, an ability to find common ground, to provide constructive feedback and to build and support high performing teams.

These skills have been reflected in many books and articles on effective leadership and also surfaced when exploring the leader’s impact on the culture for innovation. We found that “Leaders have a disproportionately large effect on the cultures of organisations and systems. By their behaviours, leaders create the conditions that either hinder or aid innovation.”  ( 2010 Maher, Plsek, Price Mugglestone). This relates to all of our time at work. If the leader is moody, ruthless and negative it is likely that the part of the organisation they are in will reflect that tone with a climate that is filled with anxiety, fear and staff who underperform. If the leader is authentically positive, empowering, curious and trustworthy, staff are more likely to be inspired, have high participation and teamwork and are more likely to achieve goals that are stretching.

I have personally had the pleasure of working with leaders who have emotional intelligence. The feeling is palpably positive: not naively so, as all organisations have challenges, but there is a strong belief and passion to work to solve those challenges and a recognition that each person in a team or organisation can help to make that difference. I have also been in the position of working with leaders who have low emotional intelligence and witnessed the destruction that leaves. Staff who are very talented lose their self-esteem, feel crushed, become suspicious of one another and become sad and unproductive. I expect as you read through this you can also picture in your own mind your experiences of both types of leader. Which type of leader would you like to work with and, more importantly, which one do you aspire to be?

‘It’s about the people’, and a fundamental part of the leader’s role is to support the people we work with and those we serve. Goleman says “Modern medical care too often lacks emotional intelligence” (p 165). For patients and families each interaction with staff creates a potential for reassurance, explanation and dialogue, yet we often miss that opportunity for an emotional connection. ‘I have not got time’ is often the cry. Think seriously, think honestly and think creatively; if it was you or a member of your family, what would you need, want or expect from that interaction? Others are practising this level of emotional intelligence and connection. Learn from them. The same can be said for interacting with staff. Each interaction a leader has with staff is a fantastic opportunity for a positive connection leaving both people with a sense of purpose. There are many great role models. I urge every reader to find one and learn. Even if you already recognise and use some of the skills of emotional intelligence, we can all always learn more from each other.

All of us are privileged to be in leadership positions. Leadership is not the domain of those who may be senior in the organisational hierarchy; we are all leaders. Focussing on building your emotional intelligence will provide wonderful opportunities to work with individuals and teams to help reach both their and your full potential.
Goleman D. (1996) Emotional Intelligence – Why It Can Matter More Than IQ. Bloomsbury Publishing. London.
Maher L, Plsek P, Price J, Mugglestone M. (2010) A Practical Guide to Creating the Culture for Innovation. NHS Institute for Innovation and Improvement.

Co-Production – Radical roots, radical results

Co-production has become something of a buzzword often used as a rebadging of patient/service user involvement. The reason for this is that the system tends to co-opt and dilute more radical concepts in order perhaps to be able to slot them into existing structures without the risky and scary business of actual transformation.

The aim of this piece then is to go back to the radical roots of Co-production. Looking behind the buzzword early on created in me a pilot light that ignites when genuine Co-production is present and a warning bell that rings when it is being talked about but is there in name only.

It is about seeing people not just as bundles of needs but as possessors of assets irrespective of how “throwaway” Edgar Cahn society may consider them. Many people are working co–productively without being aware of it. It is not a model; it is a way of being, acting and thinking and as such is hard to define.

In The Challenge of Co-production, the New Economics Foundation defines it as follows:

“Co-production means delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbors. Where activities are co-produced in this way, both services and neighborhoods become far more effective agents of change” (NEF 2009)

The key words are “equal” “reciprocal” and “agents of change”. It is not a synonym for public engagement, service user involvement or consultation. It is not just allowing people a say in decisions about themselves individually or collectively. Above all, it is not something that retains power in the hands of professionals with the patient or service user brought in at a later stage.

Elinor Ostrom first used the term at Indiana University on receipt of the Nobel Prize, which came as a surprise to many.

The key point she was making was that public services were shown to work best when designed and run by a combination of professional expertise and community insight. Ostrom’s work divides participation into individual and collective levels, very relevant to health care. We can participate as individuals, in terms of how we take responsibility for our health and in sharing decisions with professionals. We can also link up with others either with similar issues or set of values to participate on a wider level in order to create the social movement of which Simon Stephens talks in the Five Year Forward Review. Ostrom developed in a healthcare context.

Co-production was taken further by Professor Edgar Cahn, a US civil rights lawyer and speechwriter for Robert Kennedy, who suffered a massive coronary at 45. Time spent pondering in his hospital bed upon the resulting apparent loss of self and achievements before he was ill. He used this time well as he went on to found the Time Banking movement – the practical means whereby those declared useless by society for whatever reason are now valued for their assets, skills and life experience.

I read his seminal work “No More Throwaway People” and it immediately resonated, particularly regarding the feeling that his heart attack seemed to rob him of more than just his health.

“I didn’t like feeling useless. My idea of who I was – the “me” that I valued – was someone who could be special for others, who could do something they needed. And here I was, a passive recipient of everyone else’s help” (Cahn, 2000)

Here is a useful summary of the first part of the book from Time Banking New Zealand. The female author earned Time Bank credits for her efforts:

Even more succinct: an animation that distils the central tenets of the book into three minutes – the Parable of the Blobs and Squares.

Perhaps time to reflect – are we blobs or squares? Does our job title or other labels require us to change our basic shape in order to fit?

Time banking is a useful tool to enable organisations to make the traditional patient and public involvement more co-productive by addressing the key core principle of reciprocity. My experience giving my time for nothing as an active service user, at times, felt undervalued. Often the only unpaid person present facing an over-riding assumption that the only skills and experience I had were those related to my illness. I was not motivated by material gain but wondered what these assumptions said about my worth.

There was something about Cahn’s examination of what worth and value means that really spoke to me. I decided to try to see theory in practice by working at the Holy Cross Centre Trust in Camden where Cahn acted as an adviser. I got paid for every hour of my time in one Time Bank credit that I “spent” on accredited training. Being tangibly rewarded for my time restored a sense of worth that the years of illness, unemployment, passivity and largely tokenistic service user involvement had removed. It changed how I viewed myself.

David Boyle explores this concept further in the following article from the Guardian Healthcare Network:

Time banking is one of many ways in which patients/service users can be given a tangible indication of the level at which our contribution is valued. Many of us are unable to accept money or choose not to. My contributions were recognised in the form of genuine opportunities for training and development, such as my Quality Improvement Fellowship with CLAHRC North West London and being given a place on one of the NHS Leadership Academy programmes. These were life-changing opportunities that enabled me to reconnect with the skills and assets that had become frozen over the long period of my illness and gain new ones. It was a major step towards where I am now, working for myself and no longer totally dependent on Benefits.

I wrote more about my personal experience of this in this blog for the NHS Leadership Academy

Our health and social care services cannot afford to allow the insight and other life skills that people using health and social care services possess to continue to go to waste. The only way forward is genuine collaboration – that powerful bringing together on an equal basis of lived experience and professional expertise. This can be challenging for all concerned. It involves redefining our jobs that may have become part of our very identities, coming out of comfort zones and being prepared to admit that we may at best only have part of the answer.

Bovaird et al described Co-production as a radical experiment in policy innovation. Read the full article here.

In Co-production: Manifesto for Growing the Core Economy Cahn warns in the foreword of the consequence of failing to heed this message:

“We will be unable to create the core economy of the future so long as we live in a bifurcated world where all social problems are relegated either to paid professionals or to volunteers whose role is typically restricted to functioning as free labour within the silos of the non-profit world. It will take massive labour of all kinds by all to build the core economy of the future – an economy based on relationships and mutuality, on trust and engagement, on speaking and listening and caring – and above all on authentic respect. We will not get there simply by expanding an entitlement system that apportions public benefits based on negatives and deficiencies: what one lacks, what disability one has, what misfortune one has suffered….Finally, because time banking and co-production grow out of my life and work in the civil rights movement, I have to add that hell-raising is a critical part of coproduction and of the labour that it entails and must value. Those with wealth, power, authority and credentials hold those assets as stewards for those who came before and in trust for those yet unborn.” (NEF, 2008)

I echo Cahn’s rallying cry. This is very far from the rather safe world of the traditional patient and public involvement so often talked about as Co-production. It can feel messy and risky. If we can take the risk of emerging from our boxes of “patient” or “professional” and venture into the territory where boundaries are blurred, and both “sides” are prepared to walk in the shoes of the other, then we have the potential to create something of radically new. This is not about professionals having to relinquish power in an already chaotic and uncertain climate, but about strengthening the power base so there is more of it to go around.

Edgar Cahn called me a hell raiser when we met. It takes one to know one.

Examples of NESTA Co-production Practitioners’ Network and Governance International’s show this work in practice.


The spirit of the volunteer in transformational change

The health and care system would be on its knees without the efforts of an army of volunteers who give generously and freely of their time and who are dedicated to the services and patient groups they support. There is untapped potential for volunteers to make an even greater contribution. Volunteers are special people. They do what they do because they want to, not because they have to. This brings a special energy to their role, driven by values and a sense of doing something that is important and worthwhile.

The people who take part in NHS Change Day also radiate this voluntary spirit. Across England (and on other Change Days in healthcare systems across the world), thousands of people choose to take small actions to make a difference to the experience and outcomes of care for patients. The people who co-ordinate Change Day across England also do so on a voluntary basis. There are so many wonderful stories of the impact of this voluntary action for improvement. Multiple small actions can lead to a great deal of change across the whole system. It also supports a shift in power; building a sense amongst front line staff that we don’t need permission to make improvements to our own services.

So what would it take to maintain this spirit across the whole health and care workforce, not just on Change Day but the whole year round? What if leaders regarded everyone in their teams as “volunteers”, whether paid or not, and supported people to take action because they want to rather than have to; leading change in ways so it is embraced, not imposed? This was the provocation of the leadership thinker Peter Drucker when he called on all leaders to, “Accept the fact that we have to treat almost anybody as a volunteer.”

Gary Hamel also supports this volunteerism mindset for leaders but thinks that in many organisations there is a significant gap between potential and reality:

“Managers know how to command obedience and diligence, but most are clueless when it comes to galvanizing the sort of volunteerism that animates life on the social web. Initiative, imagination and passion can’t be commanded—they’re gifts.”

Dan Rockwell asks, “How would things change if you ignored the fact that employees are paid and treated them like volunteers?” He suggests we would:

• Focus more on people with passion and less on people with talent
• Seek agreement on expectations and deliverables
• Ask permission to hold people accountable
• Express gratitude sincerely
• Address tough conversations kindly
• Focus on aligning organisational and individual values
• Build relationships
• Listen
• Include
• Respect

For his latest book Accelerate, John Kotter has studied the way that change is accelerating across industries and is becoming more disruptive. He concludes that the traditional ways of organising change, via hierarchical structures and performance management systems, committees and sub committees won’t create impact at the pace and scale required to stay ahead of the curve. Rather, it needs a large number of engaged, energised individuals and that isn’t something a leader can mandate or programme, manage. Kotter concludes that leaders will get better outcomes from their efforts at transformational change if they build a “volunteer army” of staff from every level of the organisation as the “engine” or energy source for change efforts. This network of volunteers should sit alongside the hierarchical mechanisms in a “dual operating system” for change.

Stephen Covey, one of the world’s most influential leadership thinkers, died in 2012. The last thing he wrote was the foreword to a book, Turn the ship around. The words in this foreword are a prediction for the future:

“Our world’s bright future will be built by people who have discovered that leadership is the enabling art. It is the art of releasing human talent and potential. You may be able to ‘buy’ a person’s back with a paycheck, position, power or fear but a human being’s genius, loyalty and tenacious creativity are volunteered only.

The world’s greatest problems will be solved by passionate, unleashed ‘volunteers.’”

Too often we treat people as conscripts when we should treat them as volunteers and we are left with a situation where front line staff in health and care feel powerless to make even the smallest changes in their services. So maybe the legions of people taking action to make a difference for NHS Change Day and the millions of people who volunteer for the English NHS week in and week out are some of our best role models for change. Maybe leaders of health and care might climb on the shoulders of these giants.


Social learning in a social era

The School for Health and Care Radicals uses social learning principles to enable change activists in the NHS to capitalise on opportunities arising in the social era. This classics piece explains what social learning is, how the social era is different to the industrial era and how the two combined can lead to an explosive release of energy and action for change in health and social care.


What is social learning?

The way in which organisations develop their employees depends on their assumptions about how learning happens. If they think that learning happens through observation and practice through joint activity, they invest in creating platforms for collaboration, for timely sharing of experiences, story-telling and experimentation.

You may have experienced this kind of employee development. You may also have experienced the kind of development that is underpinned by behaviourist, cognitivist and constructivist models of learning. It is most likely that you have experienced a combination of these:


The impact of implicit learning models on what organisations do:

Learning models Assumptions about learning What organisations do
Behaviourist model Learning is about moulding behaviour Reward good behaviour and punish bad behaviour
Cognitivist model Learning is about integrating an explanation Provide training via lectures, talks, tests
Constructivist model Learning is about working out the question for yourself Provide coaching and facilitation
Social model Learning is about observation and practice through joint activity Provide platforms for timely sharing of experiences and stories between people as well as community self-organising


Bandura’s (1991) ‘Social Cognitive Theory of Self-Regulation‘ states that social learning is a powerful lever for change. He thought that when learners are given the opportunity to observe others, they very quickly process new knowledge and act upon it based on internal regulators such as ethical standards and self-efficacy. To the learner, they are simply engaging in social activity but actually, they are unconsciously learning (Vygotsky, 1962; Marsick & Watkins, 2001).

Rogers (2013) in ‘Diffusions of Innovation‘ emphasised the importance of giving learners the opportunity to experiment: the feedback gained from experimentation (successful or not) enables deeper learning. For example, PDSA (Plan Do Study Act) cycles are commonly used in organisations that deploy quality improvement methods as an organisational learning strategy. However, the crucial step of acting on what one has learned can be very hard to take, in organisational environments where fear and risk are high. Context is everything. However, as the School for Health and Care Radicals demonstrates and as Bandura believed, difficult contexts can be mediated by informal networks which support the individual and develop high levels of self-efficacy and drive towards a common purpose.

One important feature of the social model of learning is that it provides opportunities for individuals to share tacit knowledge. Tacit knowledge is characterised by a memory for specific events and knowledge that we are unable to explain (Polanyi, 1967). When people tell stories and have conversations about their experiences they begin to convert tacit knowledge into explicit knowledge (Kolb, 1984).

In an organisational context,

“The conversion of tacit knowledge to explicit knowledge is critical because it is a prerequisite to the knowledge amplification process wherein knowledge becomes part of an organisations’ knowledge networks” (Herschel, Nemati, Steiger, 2001:107)

Networks and communities of practice provide safe places for learners to construct explicit knowledge based on tacit knowledge sharing. They may also motivate individuals to experiment with new ways of working informed by this new knowledge, by enhancing their sense of purpose/ethical obligation and self-efficacy.

Lave & Wenger (1991) explained how newcomers are socialised into communities. They start from the margins of the community and gradually move from ‘legitimate peripheral participation’ into ‘full participation’. They learn how to talk, how to behave by interacting and tuning themselves with existing participants. As they become enculturated, they move towards the centre of the community, embracing traditional values and ways of doing things and becoming more empowered to act on behalf of the community.

Engestrom (1999) identified the value of boundary-spanners – people who work at the edge of networks enabling cross-fertilisation of knowledge between different contexts. In the social era, boundary-crossing is much easier and, therefore, more diverse points-of-view can influence how organisations change.


What characterises the social era?

Interaction on social media platforms has become widespread. In the UK, over eight in ten of adults go online and over two-thirds of those have a current social networking site profile (Ofcom, 2014).  The most popular platforms are Facebook, Twitter, Youtube and Linkedin, which are used for personal purposes in 76% of the cases (CIPD, 2013). 26.6% of people use social networking for work purposes (in 2013), and this number is growing. So organisations are now beginning to exploit their potential.

These brave organisations are seeing fundamental shifts in power, leadership focus, how products and services are developed and what defines their competitive strategy:


Comparing the social era with the industrial age:

Industrial age Social era
Power Boardroom Living room
Leadership Campaigning Engaging
Products & Services Organisation defines the “offer” Community defines the “offer.”
Competitive strategy Price Trust

Adapted from Peter Aceto (In Coine & Babbitt, 2014)


This shows how the social era represents a “monumental shift in the way we think work and live” Coine & Babbitt (2014: p8).

And it couldn’t come at a better time.

In the past, social collaboration was so undervalued, that the potential of social learning could never be reached.  Oscar Berg said, “the majority of the value-creation activities in an enterprise are hidden and thus not recognised or valued”. What the social era offers, is an opportunity to increase the visibility of social collaboration: Oscar Berg: The Collaboration Pyramid Revisited

As the social era increases the visibility and value of social collaboration, so communication and learning becomes democratised. Infrastructure no longer controls the distribution of knowledge and power. Dialogue can now happen on level playing fields between health professionals and patients, clinical and corporate functions and other diverse perspectives where silos and barriers have been constructed and previously hindered change. At the centre of this new world of “connectivism” is the opportunity to connect on common purpose. In social spaces, purpose is combined with key activities that enable change: Julian Stodd – From Intent to Purpose: stages of community.


Watching social learning flourish in a social era

Albert Bandura is now 90 years old. Do you think he notices the sheer scale of opportunity that the social era offers our capacity for social learning? For example:

* We can now observe many more people at work (e.g. through blogging and Working Out Loud).

* We can build our self-efficacy and connection to purpose through social support from the masses, which in turn encourages us to take action. For example, one tweet from a member of the School for Health and Care Radicals recently said, “ It’s encouraging to make changes when you know others are on your side #SHCR dare to do it rather than not do it :)”

* We can seek feedback from our networks on the action for change that we take.

* We can connect with people who amplify our impact, which in turn will convert tacit knowledge into explicit knowledge – the type of knowledge that becomes “known” in organisational networks and influences their direction of travel.

* We can all be Engestrom-like boundary spanners – thereby bringing thought diversity and better change solutions to the table.

The world is moving quicker than ever before – complexity rules our work and to keep up, organisations have to be agile. This means harnessing the leadership potential of those working on the edge of organisations. Social models of learning provide a structure for releasing this social capital. The social era provides the ecosystem for social learning to truly flourish.



This classics piece was  written by Dr. Rosanna Hunt, @rosielhunt Research Associate in the Horizons Group at NHS Improving Quality and Stella Martorana, @StellaMartorana Research Associate @CIPD

Resilient Radicals

I was very proud to graduate from the School for Health and Care Radicals in 2014. Taking part in this inaugural and revolutionary programme marked a real turning point in my career, not only helping me make a very important (and long overdue) decision about my next steps, but in firming up my thinking and psychological resilience.

A risk factor is usually defined as something that increases the likelihood of a future negative outcome. The converse of risk being a protective factor: a variable that decreases or buffers against such probability. As individuals, with very differing DNA, backgrounds and experiences, we all possess our own repertoire of risk and protective factors that may be activated in a high demand or challenging environment; probably just the kind of environment that we encounter as agents of change! I don’t want to dwell on risk factors in this piece; it isn’t necessarily helpful, and it isn’t in the spirit of what I’m trying to convey. I’d rather “flip it” and look at a couple of the concepts revealed for us by the discipline of Positive Psychology.

You may well be familiar with the work of Abraham Maslow, most famously his model of ‘Hierarchy of Needs’ but also his major contributions to psychology with theories on motivation, needs and self-actualisation and peak experience. Maslow commented that,

“The science of psychology has been far more successful on the negative than on the positive side; it has revealed to us much about man’s shortcomings, his illnesses, his sins, but little about his potentialities, his virtues, his achievable aspirations, or his psychological height.” (Maslow, 1954)

Applied to change activism in health and care, I wonder if Maslow’s quote resonates with anyone reading this piece? How often are we forced to focus (and left to dwell) on shortcomings, failures and criticisms? Other than at the opening ceremony of the 2012 Olympic Games, when was the last time we really celebrated the NHS for its achievements, greatness and worldwide respect? How often do we reframe illness or deficits as wellness or assets? As an employee, manager, parent, partner…what is the likely ratio of negative to positive comments we make in any given day?

As human beings, it’s unsurprising that we may be programmed to attend to the negative before the positive. This ‘negativity bias’ is an entirely functional evolutionary sensitivity to risk – to keep us out of harm’s way. As a species, it has served us well, but as change activists, it can lead us astray from our goals or begin to doubt our ability to cope and succeed.

Positive psychology is concerned with the science of wellbeing and optimal functioning, particularly the concepts of happiness, optimism and helplessness, mindfulness, character/strength/values, positive thinking, hope and resilience.

Of particular relevance to change agents is the notion of perceived self-efficacy, “People’s beliefs about their capabilities to succeed in specific situations” (Albert Bandura, 1986). Self-efficacy influences how we feel, think, motivate ourselves and behave; it will determine whether a. we decide to take action b. how much effort we need to put into the action and c. how long we persevere in the face of obstacles or setbacks. These are all critical to change activism.

Bandura said, “People’s levels of motivation, affective states, and actions are based more on what they believe than on what is objectively true.” Self-efficacy is key concept taught by the School for Health and Care Radicals (Module 1: : Being a Health and Care Radical – Change starts with me, slides 40-47) originating from Deborah Meyerson’s book “Tempered Radicals: How People use Difference to Inspire Change at Work” (Meyerson, 2001). Self-efficacy is about our belief to personally be able to create change, and there is a positive, significant relationship between self-efficacy beliefs and their ability to facilitate change and get good outcomes.

Social reformers hold strong the belief that they are capable and equipped to mobilise the collective effort needed to bring about social change. Although their beliefs are rarely fully realised, they can sustain reform efforts that achieve important gains. Were they to be entirely realistic about the prospects of transforming social systems, they might either forego the endeavour or fall easy victim to failure and doubters. Realists may adapt well to existing realities, but those with a tenacious self-efficacy are likely to change those realities.

The good news is that self-efficacy can be learned and nurtured. The School for Health and Care Radicals gives us some tactics to build our own sense of self-efficacy:

  1. Invest in your own change agent development; this is an easy one to achieve, simply register for the 2015 School for Health and Care Radicals)
  1. Create a change one step at a time: otherwise termed ‘mastery experiences’ by Bandura, this involves repeatedly achieving small goals through perseverance and overcoming obstacles. However, if the goals or tasks are always easy or too similar to the last and difficult, more anxiety-provoking goals are always avoided, then a strong sense of self-inefficacy will develop. The message here is to regularly (yet kindly) strive to push ourselves outside our comfort zone.
  1. Reframe your thinking: this is where failed attempts are learning opportunities and uncertainty becomes curiosity (by sticking it out through tough times, we emerge stronger from adversity). I particularly enjoyed a recent blog post by Paul Taylor @PaulBromfordHow to get better at failing”. Paul shared this wonderful quote from Neil Gaiman (writer and producer), “Make new mistakes. Make glorious, amazing mistakes. Make mistakes nobody’s ever made before.” In this short interview with Malcolm Gladwell, we hear a heart-warming perspective on, “Why you need adversity to succeed” where the notion of ‘undesirable difficulties’ is turned inside-out into ‘desirable difficulties’.
  1. Make change and learning cycles from change routine rather than an exceptional activity.
  1. Get social, get support! Referring to the work of John Cacioppo et al. (2011), we know that early in our history as a species, we survived and prospered only by banding together – in pairs, families, tribes – to provide mutual protection and assistance. We also know that social support predicts both psychological and physical outcomes during times of disruption and stress (The Stress Buffering Hypothesis: Cohen and Wills, 1985). Social movements are a powerful force for change, as described in this previous classics piece by @HelenBevan in Issue 1 of The Edge: What can health and care improvement learn from social movements? When we look at the common characteristics that underlie social movements: energy, mass, passion, commitment, pace and momentum, spread and longevity (Bate, Bevan and Robert, 2004) the case for ‘getting social’ in our efforts gets stronger still.
  1. Learn from the best; seeing others who are similar to ourselves succeed, raises our beliefs that we too possess the capability to achieve. Interestingly, we are more likely to benefit from role modelling (vicarious experience) when we can see that our role model has struggled imperfectly, but succeeded in a similar task. This reminds me of one of the values of Working Out Loud, (by @JohnStepper) which is described perfectly by Moyra Mackie in her blog, ‘Why everyone should be working out loud‘, “…in becoming visible we become vulnerable and in seeking to make our work better we show ourselves as fallible…”  Indeed, the most courageous and compelling leadership I have witnessed stands out to me because of its readiness to show ‘working outs’ and human fallibility.
  1. Get encouragement from people whose opinions you value; have a think about who you can identify that you trust, who has the competencies and proficiency to which you aspire?

Alongside self-efficacy neatly sits the phenomena of optimism.

“What we want is not blind optimism, but flexible optimism – optimism with its eyes open. We must be able to use pessimism’s keen sense of reality when we need it, but without having to dwell in its dark shadows.” (Martin Seligman, Learned Optimism, 2006).

I really enjoy the website BrainPickings from Maria Popova, @BrainPicker, which alongside a wealth of resources, information and thinking about what Maria calls, “…that grand question of how to live, and how to live well”, gives a concise overview of ‘Learned Optimism’ the renowned book by Martin Seligman.

“Optimism Lifts” is a great blog post by @LoisKelly, one half of the duo of the essential reading for change activists, ‘Rebels at Work: A handbook for leading change from within’ (Lois Kelly and Carmen Medina, 2014). Lois tells us how (unsurprisingly) optimistic people achieve more but equips us with some key practices to help us inject a little more optimism into our day-to-day life. Lois quotes from, ‘Rainy Brain, Sunny Brain’ (Elaine Fox, 2012).

“Optimism is not so much about feeling happy, nor necessarily a belief that everything will be fine, but about how we respond when times get tough…optimists tend to keep going, even when it seems as if the whole world is against them.” (Elaine Fox, 2012)

This isn’t about ‘happiology’ or blindly ignoring risks, pitfalls and hunches at the expense of being an unwavering positive beam of optimism. The notion of this classics piece is to remind us that we all have a choice about how we respond to any given situation. We also have a choice as to how we respond to our thoughts. The great thing about thoughts is that they are just that, thoughts. They are not facts, predictions or premonitions. You may well find your thoughts to be (on the whole) accurate and grounded, but this doesn’t mean that you don’t fall foul of the odd negative or unhelpful thought that might block your progress or success as a change activist. In order to be courageous and enigmatic in our attitudes and behaviours, in a way that mobilises others, we can all benefit from building our own mental toolkit of resources.

A man is but a product of his thoughts. What he thinks, he becomes.” (Mahatma Ghandi)

Further learning:

If you’re interested in Positive Psychology and would like to learn more, why not sign-up for this free MOOC (online course) with Dr. Barbara L. Fredrickson from The University of North Carolina at Chapel Hill. The MOOC starts on 9th February 2015 and runs for six weeks.

Readiness for change

The focus of the “classics” in this third issue of The Edge is “readiness for change”.

For any change agent in health and care, “readiness for change” is a key issue. It is the extent to which the environment in which we find ourselves as change agents is actually receptive to change and therefore, whether the change can be delivered, sustained and spread further.

This piece was stimulated by a recent blog by Adi Gaskell called “Do you really want to be a radical?” He stresses just how big a part environment plays in how we behave.  In a conductive environment for change, we might be “boatrockers”, positively challenging the status quo and leading change. In a more challenging environment, we might find ourselves as “troublemakers”, full of grievances and anger and not getting very far. The system and environment we operate within therefore has to support creativity and innovation if people are to have a hope of obtaining it. It is one of our key roles as change activists in health and care to build readiness for change.

I have spent more than 30 years leading and facilitating large scale complex change programmes. Early in my career, I thought that programmatic change interventions provided “magic” for improvement. I thought that if, as a change team, we created powerful aims for change, designed measurement systems, built improvement skills and got teams to collaborate, we could make improvement happen. What I have learnt over the years is that the “magic” really happens when teams come together with a burning passion for improvement, where shared purpose overcomes power issues and the local conditions are ripe for change to happen.

I cut my teeth on large scale complex change in the early 1990s, leading The Leicester Royal infirmary Re-engineering Programme. This was the largest, most ambitious change programme ever undertaken by a single hospital system. The aim was to literally “re-engineer” all the core processes of the hospital and create big improvements for patients. This programme became so famous (or infamous!) that it continued to be quoted for another two decades,  such as in Edward Peck’s book on Organisational Development in Healthcare (2005)and in this 2012 report on cost and quality in hospital by the Nuffield Trust. One of the best studies ever written on the conditions for change in healthcare was the evaluation of this LRI programme, Reengineering Health Care: The Complexities of Organizational Transformation by Terry McNulty and Ewan Ferlie, published in 2002. One of the challenges with this book is that the language it uses makes it virtually impenetrable (and therefore unusable) to a practitioner audience. None the less, I still assert that if the learning from this research study was practically applied in subsequent large scale change efforts, many fewer mistakes would have been made and the transformation of health and care would be much further forward.

Essentially, McNulty and Ferlie conclude that whilst there were notable successes at The Leicester Royal infirmary, the impact of the change programme was “uneven” and the change process was evolutionary and incremental rather than the large scale transformational change sought. This was largely a consequence of the pronounced influence of the very organisational setting that the programme sought to change. The issue of the power of the medical consultants in the hospital (and their ability to promote or block change) was pivotal. The way the change process was implemented had to be sensitive to the nature of medical work, and the need to negotiate change with the medical consultants. Despite the fact that the senior leaders supported and actively led the change programme, this was not enough to ensure change across the organisation.  There are many lessons here about “readiness for change” that we will build on further in this classics piece.

The next major change programme I worked on was also the topic of formal evaluation which provided important insight on “readiness for change”.  This was the National Booked Admissions Programme, initiated in 1998. Across England, 24 pilot sites were identified to test novel ways to enable NHS patients to book hospital appointments at a time to suit them. The evaluation was carried out by Chris Ham and colleagues from the University of Birmingham and published in 2002.

All the pilot sites made rapid progress in the first year but there was slipping back in some of the localities in the second year and a wide variation in what was achieved between the pilot sites. This might seem surprising: after all, all the pilots were chosen because they had strong characteristics for change, they all received programme management support, extensive training and the support of peers. A variety of factors give insight into the uneven outcomes. Pilots with a receptive context (“readiness”) for change did best. Localities with an existing history of positive change and previous booking efforts, effective leadership by a chief executive and senior clinicians, a dedicated project manager and team, and a flexibility of approach to clinicians did better than pilots without these characteristics

As with the Leicester Royal Infirmary programme, the “booked admissions” evaluation highlighted the inherent challenges involved in achieving change in a professional bureaucracy. What might seem to be a relatively incremental step –offering patients the choice of dates for appointment, instead of placing them on a waiting list – in practice entails a complex and interlocking series of actions. This study teaches us that there are no magic bullet solutions to the challenge of change in health and care. Twelve years later, the same conclusions apply: each setting for change is a unique local context; the main source of change and service improvement has to come from within and around each and every NHS organisation.

How we view “readiness for change” depends on how we define the reality of change. Many of the “change readiness assessment  tools” that are currently available to us as change agents are based on the principle that there is an external “thing” out there called the system or organisation that can be diagnosed and treated in the same way that a biological system can. Therefore the questions about readiness for change are often about having all the technical capabilities for change in place. For me, the problem with these approaches is that they are too simplistic and can’t explain away or predict the human dynamics; they don’t start from the position that the system that we are trying to change is a complex set of interpersonal relationships. If we take nothing else from the previous studies, we have to take account of people with diverse needs, perspectives, priorities and power bases.

I am therefore much more comfortable with the approach to readiness for change that is suggested by Bryan Weiner in his paper A theory of organizational readiness for change (2009) He regards organisational readiness for change as a shared team property. Rather than an external reality that is “out there”, readiness for change is a shared psychological state (a collective reality) in which people in the organisation or system feel committed to implementing a change and confident in their collective abilities to do so; where changes in delivery of health and care require collective, coordinated behaviour change by many different people. Weiner’s approach has been subsequently developed into a psychometric test for measuring organisational readiness for implementing change by Christopher Shea and colleagues

Similar themes are carried into one of the most insightful studies about readiness for change in recent years; Explaining Matching Michigan: an ethnographic study of a patient safety program published by Mary Dixon-Woods and colleagues in 2013. Matching Michigan was an ambitious national programme, launched across England, to reduce central line catheter-related bloodstream infections and match the dramatic results achieved in more than a hundred Intensive Care Units in Michigan that had tackled the issues in a similar programmatic way.

The Intensive Care Units that the researchers studied were categorised as “transformed”, “boosted” or “low impact” as a result of the Matching Michigan programme. The low impact group was the big majority. What the researchers found was that these were complex, multi-factor environments at play that were not always easy to categorise or explain. However, the single most important influence on how individual units responded – either in promoting or resisting change – was the extent of consensus and coalition among the senior medical and nursing staff on individual ICUs. The commitment, characteristics and skills of local clinical leads was at the heart of how much change took place.  Transforming or boosting of efforts was most likely to occur when the clinical leaders charged with making change happen were sincere and authentic  in their beliefs about the value of the Matching Michigan program and the way they put that across. Other important factors were their ability to create alliances that crossed clinical disciplines, how much credibility they had among their  local peers, were prepared to tolerate debate and dissent but exercise firmness, and used multiple tactics involving both intrinsic and extrinsic motivation, including role modelling, persuasion, sanctioning, reminders and constant feedback. The authors stress the importance of distinguishing technical interventions from implementation strategies, and the need for careful attention to the contexts in which improvement programs are introduced. .Actually, these are similar themes to those suggested by McNulty and Ferlie and Chris Ham and colleagues more than a decade ago.

So which tools for assessing readiness for change would I recommend? The tools I use most are those designed for assessing spread, adoption and sustainability in a healthcare context. Why? Because, as much of the research I have already quoted shows, there is a clear relationship between readiness for change, the extent to which change is likely to be sustained and its ability to spread. Here’s an Improvement Leader’s Guide that explains it further.

I often use the NHS Sustainability Model and Guide which helps us to identify the strengths and weaknesses in our implementation plans and predict the likelihood of sustainability. There are also three videos that go with the guide.

I also find this online tool to assess the likelihood of spread and adoption to be very useful. Both these tools are built on an extensive empirical evidence base. For me, the power of these tools is in the conversations that they spark between key stakeholders, and the different conversations they allow, rather than their predictive abilities.

If we look back over the past two decades we can see just how much effort we could save ourselves by considering readiness for change more reflectively and creating the conditions where change and innovation can flourish, rather than rushing into action and/or designing programmatic interventions. Of course readiness for change means putting into place all the programme and accountability systems that will build a strong governance platform for change. However, at the heart of readiness for change is the complex, interconnected web of individuals with different needs, interests, priorities, influences and previous experiences. We start from there.

What can health and care improvement learn from social movements?

The process of assembling this “classics” piece on social movement thinking for health and care improvement gave me many flashbacks to my own development as a change agent over the past 15 years. These ideas have been some of the most influential on my practice.

I first started to understand the potential of social movement ideas for healthcare improvement in 2002. At this time, I was leading programmes across the NHS in England to reduce patient waiting times for care and to improve the outcomes of care for people with cancer and heart disease. I was a strong advocate for these systematic improvement programmes but I always felt that an additional motivational element was needed. Ultimately, if we were going to enable improvements for people who use our services across the whole country, we needed to build a movement of at least a million change agents. What could we, in the healthcare improvement community, learn from the leaders of the great social movements: the Women’s Suffrage Movement, the American Civil Rights Movement, the environmental campaigners of the 1970s? These were leaders who had no hierarchical power and few resources in a conventional sense but were able to mobilise for action that literally changed the world.

I linked up with the academics Paul Bate and Glenn Robert and we started to explore the potential and possibilities. This led to the publication of our White Paper ‘Towards a million change agents’ A review of the social movements literature: implications for large scale change in the NHS. This paper has since been downloaded more than three million times! We also published our thinking in a journal article: The next phase of healthcare improvement: what can we learn from social movements?

Over the years we continued to engage with others, to develop our thinking and test practical approaches using these social movement principles. The next major publication was The power of one, the power of many: bringing social movement thinking to health and healthcare. This was the first handbook on social movement thinking and practice that was truly accessible to the healthcare improvement community. Six years after its publication, it is still widely used.

Paul Bate and Glenn Robert also continued to publish, notably Bringing Social Movement Theory to Healthcare Practice in the English National Health Service in Social movements and the Transformation of American Healthcare.

These social movement ideas started to permeate more mainstream change practice. You can see this in Leading Large Scale Change: A Practical Guide that I published with Lynne Winstanley and Paul Plsek in 2011. Techniques related to “framing and reframing” and “transformational storytelling” sit alongside measurement frameworks and stakeholders analysis. You can also read part two of the guide Leading Large Scale Change: The Postscript which is a commentary on the relevance of the principles for a contemporary audience.

In 2010, we made a connection with Marshall Ganz of the Kennedy School of Government at Harvard University. Marshall taught us many practical approaches, which, combined with our existing approaches, took our change practice to a different level. I particularly like the book chapter Leading Change that he published in 2010 which describes how organisational leaders can build their leadership capability by learning from social movement leaders.

There are now multiple examples of these social mobilisation approaches applied in a health and care context. The first one here is about using social movement principles across Engalnd to reduce unwarranted prescribing of antipsychotic drugs to people living with dementia. The second is about pioneering work in mental health issues with Māori youth in New Zealand. This New Zealand team also took part in a web seminar for NHS Wales on “empowering communities to better health”, linked to the Welsh . You can download the film here.

I made two short films for the NHS in Wales on social movement thinking. The first is about how we can unite and mobilise people around a cause for change: The second is about how social movement leaders think about resources in terms of relationships they build.

The knowledge base on social movement thinking continues to expand. Recently, Hahrie Han published a new book on civic activism. She makes the distinction between “lone wolves” (people who largely work on their own, providing information and resources), mobilisers (who encourage other people to take action) and organisers (who grow the future leaders of social movements). Of course, we aspire to be organisers! You can download the first chapter of this book. We hope that this book will be the subject of our book club in a future issue of The Edge.

Finally, this is my reading and reference list on social movement thinking and related topics relevant to health and care improvement [Social Movement Reading List]. In line with the philosophy of The Edge, every reference has a free link to the publication or a summary.

My conclusions? As activist-leaders, we can learn greatly from leaders of social movements. We need to challenge the status quo as necessary and tackle the tough issues. We need to believe that a different future is possible and that the people we work with and serve have the capability, energy and motivation to deliver the changes. Crucially, we have to understand that we cannot be a change activist or rebel on our own. Success is about our ability to call others to action and move forward on with shared purpose to achieve the outcomes we seek.

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