Is Change Day the way to foster a spirit of innovation across the NHS?

4 March 2014

You know that feeling when you come across an idea so interesting you feel you may never again see the world in the same light? That’s how I felt when one of the delightful Think About Health  conferences introduced me to the phrase ‘the metaphysics of language’ – the notion that we shape the world by the way we talk of it.

Here’s an example: we say ‘I’ve had an idea’, or ‘it was his idea’, or even ‘she was given the Nobel prize for her ideas about…’ but how do we know it was that way round? Suppose it was the idea that ‘had ‘ us? That would feel the same wouldn’t  it? One moment the idea wasn’t there, and the next it was? This is almost the territory of memes and ‘the selfish meme’, in which we and our behaviours are vehicles for the survival of the fittest idea (that is not the fittest for us, but the one that has a survival advantage among ideas!).

Alternatively we could describe an idea as an emergent property of a complex system, the idea as a result of the interaction between you and your environment. Can we really then say it was your idea, that ‘you had it’?

Both of these are more accurately described in the phrase ‘it came to me that….’  which, oddly,  we don’t seem to use so much nowadays. Why is that I wonder? Is it because intellectual property rights now form part of WTO trade agreements? Because it’s in the interests of large Corporates to have us believe that ideas belong to the person or company that ‘had’ them?

It was American sociologist Robert Merton who coined the terms ‘heroic inventor’ and  multiple discovery(that the same idea is often developed by different people quite independently of each other at about the same time), coming down solidly in favour of the latter.

Merton was a prodigiously interesting man who conceived so many valuable terms it’s difficult to imagine a working day without quoting him. ‘Role model’ for example; ‘self fulfilling prophecy’; ‘law of unintended consequences’. He was working mid 20th century, when sociology and other humanities were valued by decision makers and seen as attractive careers. Sadly they were elbowed out in the neoliberal take-over of intellectual discourse from the ‘80s onwards, and became either enslaved to the corporate world or seen as irrelevant and dismissable.

Is it any wonder that having narrowed so substantially the range of subjects studied we now have to make calls for increasing innovation? Once it could emerge spontaneously from a melting pot made up of minds approaching  a problem from a multiplicity of standpoints, now there is a dull uniformity of view. How would health care organisations look different, I wonder, if they were managed by sociologists, anthropologists, historians, geographers, theologians, graduates with English literature and fine arts degrees and others, instead of only economists and MBAs?

No, creativity and innovation need diversity in which to thrive. They also need permission. To be creative we need to feel able to make a difference. We need to feel our ideas can translate into action that will be welcomed. Although there are many benefits to protocols and guidelines the way these are implemented can lead to the opposite – a feeling that suggestions aren’t allowed, that  the protocol is fixed and unchangeable, or that new ideas must get caught up in governance procedures. . Clearly the use of evidence is vital but surely we can find ways of using it that feel empowering rather than restrictive.

Now it takes NHS Change Day  to give people the permission and motivation to make changes they could make any or every other day. The enthusiasm with which staff have embraced it indicates just how much creative energy is going untapped, and It’s terrific (and significant) that it was devised by three front line clinicians. Perhaps I am being unduly cautious  but personally I’m a little concerned that it’s been seized upon and centralised and turned into a multimillion pound splurge by NHS IQ. I’m sure it has gained in publicity and scale, but wonder whether it has it lost heart? Whether it will lose its guiding enthusiasm. If it becomes part of the centralised machinery instead of being an outsider can it enable genuinely new thinking? Isn’t creativity rather like these wild mustangs?  I wonder whether when corralled it  loses its essence, it becomes tame, it becomes something else?

So if that energy for change is there, just waiting for the permission and motivation of Change Day, how could we offer those on a more consistent basis?  Imagine that every member of staff was part of an ongoing conversation with someone more experienced than themselves about how they were doing, about their ambitions, enthusiasms and concerns, and about the performance and potential of the service. Imagine that in the course of this conversation they were supported and endorsed for things they were doing well, challenged, gently but effectively about aspects they could valuably improve upon, and generally enabled to be the best they could be. That is called management. Actually it’s what I call really managing, and I don’t see anyone doing this.

This is so vital a part of organisational life that without it we have had a vacuum, a vacuum that has inevitably filled with vastly more expensive and disempowering activities such as ‘leadership’ and ‘governance’. It’s my belief that giving senior clinicians the skills to support, challenge and enable their juniors in this way would save the NHS billions even as it improved outcomes and care experience. And that this would be a far more effective way of encouraging innovation and creativity than trying to ‘incentivise’ them, to command them, to control them, to measure the return on our investment, to set them targets, to insist on tests of ‘scaleability’.  

So I suggest that one very good use of Change Day would be to prompt us to rethink how we support front line staff – so that Change Day becomes Change Year, year in and year out.

But we also need to think wider than the NHS, after all, NHS staff form 1 in 50 of our national population, so whatever is happening in society in general will be shaping the NHS.  So we need to take an interest in the  intellectual diversity of our wider society – currently (I suggest) diminishing even faster than biodiversity. Just look at how our mainstream media have succumbed to a monochrome world in which the news conforms to stereotypical stories of goodies versus baddies that add little to our ability to understand complex arguments relevant to the world we live in.

Even the BBC (whose website, with its fantastic array of the most wonderful programme podcasts, shows us just what fantastic value this much maligned institution is, and just how much treasure can be made for such a paltry licence fee) has reduced the Today programme to a set of ridiculous jousts between opposing views on topics that require much more nuanced consideration. Question Time panelists are limited to identikit politicians (mis)quoting dead economists, and the occasional approval- seeking satirist. Imagine instead a panel of politically thoughtful  physicist, historian, social geographer and ethicist one week, followed by sociologist, biologist, political philosopher and psychologist the next. Wouldn’t those be thought-provoking discussions worth listening to?

No wonder that many of us are choosing to follow fascinating leads on Twitter instead. And that we still seek considered, well made arguments in books . (Although personally I find I have to choose between one and the other, with lengthy periods devoted to one but not both). Indeed we seem to be dividing into parallel streams of awareness: those addicted to news on demand, and those who tune in once a day (to find out whether we’ve declared war) and otherwise apply their intelligence and attention to things of importance.

As part of our wider interest we must not allow ourselves to believe that innovation is more readily fostered in the private sector, there is growing evidence  that the intellectual contribution and risk taking of the public sector dwarfs that of the private.

So, if we truly care for creativity and innovation we must challenge a lot of current assumptions. We must stop assuming the private sector is better at it, stop thinking that it has to be ‘incentivised’ and financially rewarded, and instead put in place the conditions that allow it to emerge.

We could re-widen the range of subjects supported within universities,  re-introduce apprenticeships so that more of our young people can learn-by-doing, in a supportive environment, and innovate that way too. We could reconsider university tuition fees and encourage in students a sense of commitment to society, and a desire to make a contribution.

We could call for changes in the World Trade Organisation rules on Intellectual Property Rights and re-find an ability to enjoy being part of an idea as it emerges without either slapping in a claim of ownership, or whisking it away to be up-scaled and centralised.

We could recruit people, to positions right across our organisations and our governments (from seniors  to newcomers),  who have an interesting intellectual hinterland.  

And we ourselves could start right now by picking up a book instead of a newspaper!

Idealistic? Impossible? Perhaps. But no less so than vainly hoping for fruitful valuable, health and planet saving innovations from an increasingly arid managerialist landscape. And we can each play a part in bringing it into being……


Very interesting. I have often wondered if we had social scientists for example, maybe undertaking ethnographic approaches to public inquiries, what would the recommendations look like? How much might they differ from a barrister’s view, or a politician’s? Thorough though the Francis and other public Inquiries have been, some of the recommendations might be difficult to implement, and some of the findings might have been enriched if different perspectives were at work. I certainly think a skilful qualitative researcher could have helped me discover and share some insights from my experience of working in the system responsible for the poor care provided in some wards in Mid Staffs , whereas a pugilistic inquisition, in a public gallery, rendered me incapable of coherent thought let alone speech…      Yvonne Sawbridge, Senior Fellow, Health Services Management Centre, University of Birmingham

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