Leadership, Organisational development, Staff development

Are human beings all just creatures of habit?

How do we foster a culture of innovation in healthcare?

I’m writing this as I fly back from my holiday in Crete. While I was there I couldn’t help noticing that every day the same people sat in the same places for each meal and lay on the same sun loungers by the pool. That started me thinking: are humans really just creatures of habit? Is change considered scary in organisations because, in reality, humans seek comfort in routine? Organisations are made up of human beings – and in order to have real, sustainable change the alternative has to be demonstrably better than the status quo.

A recent study into modern healthcare innovations by disruptive innovation guru and Harvard Professor Clayton Christensen concluded that, “Health care may be the most entrenched, change-averse industry in the United States.”[1]  England is arguably no different. Healthcare has been delivered in more or less the same way for decades, and in some cases even longer. Getting people to change their habits and move out of their comfort zone is a full-time occupation for many managers and leaders. Forward-thinking leaders have been using techniques such as visioning and future-basing[2] to try and get the workforce to ‘buy in’ to this change.

But are we just fighting against the tide? How easy is it to get people to really think about the future in a different way? What’s in it for them? Is this just working against human nature?

Virginia Mason, a world renowned leading US healthcare provider, would argue not. They have managed to transform how their people think about healthcare delivery over the past 20 years through the application of the healthcare version of the Toyota Production System method, or ‘Lean’ to you and me. This has enabled them to systematically integrate innovative structures, methods and lean cultural practices into their everyday ways of working. Their experience has increased the nursing to patient time from 40% to over 90%.[3] So, shouldn’t the NHS be beating a path to their door?

In my view, the answer is unquestionably ‘yes’. Once you get past all the usual arguments about why the ‘Virginia Mason Way’ would not work in the NHS, and when you strip it all back, it’s because their workforce all BELIEVE. They believe there is a better way, they believe they can improve patient experience and they believe they can always do things more efficiently and effectively. This means that the workforce are not only engaged in the change, they are the change they want to see.

As Mark Hutcheson (previous Virginia Mason Medical Centre Board Chair) said of the birth of the philosophy of the VM production system, “We want to make sure we are in existence 100 years from now, and you can only do that if you are innovative. You cannot just tread water and not embrace change because you will die. So, you’ve got to always be figuring out some way to grow, and that requires being willing to look at some things differently.” [4]

How do we start to engender the much needed change in the NHS to make sure it still exists in 100 years time? According to author Rolf Smith, from his book The Seven Levels of Change: Different Thinking for Different Results, the 7 levels of change are:

Level 1: Doing the right things: effectiveness, focus and working to priorities

Level 2: Doing things right: Efficiency, standards and variation reduction

Level 3: Doing things better: improving, thinking logically about what we are doing and listening to suggestions

Level 4: Doing away with things: cutting; asking ‘Why do we do this?’; simplifying and stopping what really doesn’t matter

Level 5: Doing things that other people are doing: observing, copying and seeking out best practices

Level 6: Doing things no one else is doing: being really different, combining existing concepts and asking ‘why not’

Level 7: Doing things that cannot be done: doing what is commonly thought to be impossible questioning basic assumptions, breaking the rules and being a bit crazy

The NHS is pretty good at the first three, but really needs to work on Levels 4 – 7 if it is going to see any discernible change.

Getting to Level 7 – really seeking to unleash the creative spirit of our staff and being ‘a bit crazy’ – is what the NHS needs. Trying to do that within the current regulatory and inspection regime is going to be the tricky bit.

Learning from the Virginia Mason experience is part of our strategy, as well as forming a learning collaborative with Sunderland NHS Foundation Trust, who are five years ahead of us on this journey. Underpinning all of this with a robust, organisational development programme that takes our 13,500 staff out of their comfort zone and unleashes their creativity whilst at the same time convincing our 900 strong medical workforce that (in the words of Dr Atul Gawande) “standardization has led to vastly better outcomes,” will be a tightrope that our organisation’s leadership will need to walk for the foreseeable future.

I aim to share our experiences in order to help leaders across the NHS learn from our experience and our (hopefully not too many) mistakes. For now I’ll leave the last word to a staff member from Virginia Mason who said, “To me, an innovative culture is one where anyone can bring up new, creative and sometimes even backward ideas, without fear of being thought of as crazy, strange or funny…. a culture where innovation is rewarded and celebrated.”

Now I bet they sit on a different sun lounger by the pool every day.

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[1] As quoted in Plesk, P; Accelerating Health Care Transformation with Lean and Innovation: The Virginia Mason Experience (2014) p19 -20

[2] A organisational development technique where you get people to imagine they are in the future, what that looks and feels like and the barriers they have overcome to get there

[3] Plesk, P; Accelerating Health Care Transformation with Lean and Innovation: The Virginia Mason Experience (2014)

[4] Plesk, P; Accelerating Health Care Transformation with Lean and Innovation: The Virginia Mason Experience; (2014)

About the author

Sarah Morgan is the Director of Organisational Development at Guy’s and St Thomas’ NHS Foundation Trust and passionate about innovation and change.


Organisational form – the silver bullet for the NHS?

The viability of the NHS is a paramount concern and one of the key issues we currently face is the lack of available workforce to deliver the care, at a high quality standard, to the population. Organisational form is one key element to consider in how we utilise our resources best, however it is not the only answer and ensuring we continue to examine the clinical models is crucial. Form follows function and so only once the clinical and requisite support models have been identified should the optimal organisational form be considered.

As the Head of the Dalton Review it was clear to me that organisation form is best considered as a delivery vehicle to execute the organisation’s strategy. In the Review Sir David Dalton asked leaders to become “‘strategic architects’: using their social entrepreneurial spirit to develop innovative solutions to their challenges and to codify and spread their success, so that the best standards of care are available, reliably, to every locality in the country.”

Although the Dalton Review examined the benefits of different organisational form, it did not champion one model over another and was clear that it was down to individual organisations to consider their own local circumstances. Organisational design is very important to get right as it is very easy to destroy the value in an organisation by executing a poor merger or acquisition or trying to force clinical services into an organisational form that is not the best fit.

In order to support leaders, the Dalton Review developed a series of practical checklists for Trust Boards to ask themselves to determine the right organisational form(s) to consider go to gov.uk to access). The organisational form should be able to support the organisation to deliver against three key areas:

  1. Strategic ambition
  2. Patient and clinical benefit
  3. Financial benefit


For those NHS leaders actively contemplating the future of their organisation, here are some key considerations when thinking about whether or not organisational form is the right answer:

More than structure – structure is powerful but a blunt instrument for influencing relationships and can often not drive the value creation that organisations expect to achieve through changes in organisational structure or form. Remember 70% of mergers fail[1]. It usually only works when supported by changes in processes, people, rewards and measures. This is important to consider the operating model and clinical model.

Relationships – effective organisation is about good people working well together: relationships. Good organisational design work is about creating the context for good working relationships.

Informal organisation – the real organisation is the informal organisation. In healthcare this is particularly powerful. How do your clinicians really get things done? What is the cultural narrative of the organisation and what is important to the staff that work there? What’s going to enhance this and retain and recruit your workforce? Organisational design should aim to improve/ enhance the informal organisation by making changes to the formal organisation.

Power – Relationships are influenced by power differences. Understanding power dynamics and how to shape them is essential to organisational design.

People – Organisations should be designed for the people who will work in them – however not just the heroic superman or superwoman leader and not only around the incumbents (unless they are fixed). Thinking about the people available that could be attracted to work in the organisation and how the design could enhance the opportunity of recruiting them.

based upon the material from Advanced Organisational Design; Ashridge Business School: adapted from Andrew Campbell and Michael Goold, Designing Effective Organisations


So, why do 70% of mergers and acquisitions fail? One of the reasons is that not enough time and thought is applied to the requisite organisational form to deliver the strategic ambition. Many leaders forget or even try to disregard the fact that organisations are made up of people and it is often the informal working practices and culture that creates the value in organisations. Underestimating the power that the culture has on the value creation of the organisation is a mistake that is made over and over again.

Common mistakes leaders make are:

  1. Creation of a new entity or organisational structure – the factors that create the value in both organisations is often destroyed in this process. Understanding how things get done (and often this is not how it appears things get done by looking at the hierarchy), and working through how best to preserve this, is key to maintaining or enhancing the value in the organisations involved in the M&A
  2. There is no such thing as the perfect organisational form – there is the optimal form, at the time, which will help to deliver the strategic ambition of the organisation. Understanding the limitations of the organisational forms, particularly the generic elements such as matrix structure or having stand-alone strategic business unit etc, will help the designers to make design choices that minimise the impact of these limitations and optimise the structural design
  3. Leaders can get wedded to organisational forms that they have designed – it is easy to come up with an organisational form that at first glance appears to be perfect, however digging a bit deeper would reveal that it could have flaws. Often, leaders do not want to dig further as doing something is often more enticing than doing nothing. This can lead to the wrong design; destruction of value and years of trying to manage the unintended consequences of poorly thought through organisational design, often playing out as cultural issues and dysfunction.


Overall, the new flexibilities afforded to the provider sector, to examine their organisational form are a fantastic opportunity, however there is a risk that the need to be seen to be ‘doing’ very quickly could leave some Boards and senior leaders across health and social care to make quick decisions on the right organisational form without thinking through all of the consequences.

We must not forget that the NHS is made up of the 1.4million people that deliver the care to our population. It is not a machine that you can get a toolkit out, dismantle and then try and rebuild more efficiently; it is a complex system and every organisation has its own unique culture.

The design of the organisational form is almost the easy bit and so easy to get wrong. Leaders need to give careful consideration to the organisational development programme that will need to be in place to underpin the change. Going through the motions of the organisational change policy; putting people into new roles and changing protocols is not enough to create a new organisation and culture. In fact, it is a recipe for disaster, despite this, it is a well-trodden path for the NHS and one we might need to think about diverging from.

Leaders need to give careful consideration to their organisational culture and their staff and think about how best to create rather than destroy value through changes to organisational form. Many leaders of financially challenged Trusts face the difficult balance of resisting being seduced by the promise of a slice of the £200m transformation fund whilst being under pressure to change organisational form quickly to ensure viability. Engaging with their staff to truly understand the organisational culture and how to get the most out of the ways of working will be vital to the success of any change.

Getting this right at scale has the exciting potential to create a viable; sustainable and more effective NHS for future generations.


About the author

Sarah Morgan is the former Head of the Dalton Review for the Department of Health and is currently the Director of Organisational Development at Guy’s and St Thomas’ NHS Foundation Trust


Materials quoted from Advanced Organisational Design course at Ashridge Business School; Led by Andrew Campbell access the link for more details https://www.ashridge.org.uk/executive-organisation-development/open-programmes/advanced-organisation-design/




[1] Research undertaken for the Dalton Review in the Literature Review access at https://www.gov.uk/government/publications/dalton-review-options-for-providers-of-nhs-care)