Democratic change management

March 2018

IT in hospital theatreJames Freed, Chief Information Officer at Health Education England, tells Martin Cooper AMBCS about Building a Digital Ready Workforce - a digital transformation programme with people, not technology, at its centre.

James Freed began his career in cancer research but soon found life in a lab wasn’t to his liking. He quit his PhD, moved to a South West London hospital and became involved in change management. The experience was a revelation and began a lifelong fascination with change, with helping people to make change and understanding what motivates people to change.

Freed next turned his attention to paper: the huge piles of paper, and the associated processes, that the NHS generates as each new patient arrives. ‘There’s no way you could ever hope to understand everything that’s recorded about the patients you’re trying to treat,’ he says.

So, back in 2003, he joined the National Programme for IT. This led to a nine-year stint at the Health Protection Agency and Public Health England where he worked as Head of Information Strategy. There he wrote the Public Health England Knowledge Strategy. ‘It’s about how we can use data, information and knowledge better, to improve public health and prevent illness and harm,’ he says.

If you don’t work in health and social care, you’ll never have heard of Health Education England. So, what does it do? ‘We’re there to provide the right skills, in the right place, in the right quantities, at the right time,’ explains Freed. The organisation, he says, manages every single junior doctor that’s in training in the NHS and plans for the workforce in the NHS, ensuring its ready to face our world of ever-changing, and ever-accelerating, change.

To create a digital-ready workforce, Freed believes the NHS faces several core challenges. Inevitably the first one is money - in these austere times there just isn’t enough available for the NHS, social care or even local government to deliver the same services, to the same level, and in the same ways they have always done.

People are living longer, often with multiple chronic illnesses. ‘All of those things add up to a rapidly increasing bill, which we are not able to keep up with,’ he says. The key to helping health and social care meet its challenges, Freed says, is do more with less - through using technology smartly and correctly. And this technical toolset, thanks in part to Moore’s Law, is becoming better and better over time.

Of course, understanding the NHS’ well documented challenges and trying to solve them with ever more elaborate technology - history shows us - is far easier said than done. Yet, it’s at this marrying of a challenge with technology - the point where change is created and managed - that he seems most at home.

Can the boardroom deliver?

‘It turns out,’ he says, ‘that, across all industries, about 60 per cent of changes are initiated by our frontline workforce... The group of people who interact with our userbase on a day-to-day basis. They’ve got problems on a day-to-day basis and they solve them on a day-to-day basis’. Frontline workers are really incentivised to make changes because it makes their life easier and it helps them do a better job.

Finishing off the run of statistics, he suggests that around 30 per cent of ideas come, historically, from middle managers and only 10 per cent from the boardroom. ‘So,’ he says, ‘the question is, how do we - as leaders - deliver this radical toolset, this digital toolset that enables radical change, to the 60 per cent, or to the people who come up with 60 per cent of the ideas? How do we deliver change to a whole workforce? That’s the idea behind Building A Digitally Ready Workforce.’

The first step in enabling change on such a grand scale is a cultural shift. Freed says: ‘To create an environment for change, we need to support a culture for change. And that culture is set by everyone in the organisation, but it is most obviously set by those people we look up to.’

In hierarchical organisations that means the boss. We look to the bosses to set the culture. We watch them, we see what they do, and we emulate those behaviours. ‘Culture,’ Freed says, by way of a summary, ‘is a grown evolution of observed and repeated behaviours.

We need our leadership to behave differently. And so, we’ve got a whole programme of work on leadership. It’s around board development and individual development. After culture come skills, knowledge and experience. January 2018 saw the launch of the Digital Academy, a scheme designed to train over 300 CIOs and CCIOs to a global standard.

‘The third piece of work is our broad work on the informatics workforce,’ he says, observing that about 50,000 people in the NHS would class themselves as informaticians - people who work with data, information, knowledge and technology on a day-to-day basis. ‘How do we help them come out of the back room and instead become champions, leaders and even educators?’

The final piece of the jigsaw is around digital literacy, and it’s a huge challenge - a three-million-person challenge. To make the challenge manageable, Freed and his team have focussed initially on nurses. ‘We will be identifying the tools, techniques, learning and indeed barriers that get in the way of nurses... That’s where we will be investing our time, our effort and our money.’

Democracy in action

The traditional model for making grand, organisation level changes is for the person given the challenge of delivering change to retreat into a room with a team. They come up with a plan and this is presented to the staff as: The future.

Freed feels that this is the wrong approach. ‘The biggest thing I’ve learned from change management is that it is really hard to do that to people,’ he says. ‘People are afraid of what they can’t control. And I understand that. I don’t want to be told what to do. I want to be a master of my own destiny.’

‘It comes down to a principle: people are afraid of change being done to them,’ Freed enthuses. ‘If they feel in control of the change, it ceases to become scary. Or less scary, I should say. Anyone who’s moved house... it’s still damn scary, isn’t it? But it’s important that people do choose to move house.’

‘Gather speed again’, he says: ‘It needs to be more than testing though. Just getting an end-user involved in testing is a what? A two decades, three decades-old idea? It’s necessary, but it is not sufficient. You want end-users to own the product, which we are providing for them; we develop it in collaboration. The important word for me is not “testing”, it’s “ownership”.’

For this reason, Health Education England turned to an unlikely bedfellow: crowdsourcing. ‘The more we involve people in designing what the future world is going to be, the more they’re going to want to change to meet that future design. Because it’s them who’ve designed it,’ he says.

Freed partnered with Clever Together, a company who have developed an approach to derive complex ideas from many diverse views which, in this case, took the form of a three-week long online workshop. ‘We had 1,136 respondents - unique respondents - that contributed collectively 4,000 ideas, comments and votes,’ he says. The processes’ aim was to be meritocratic and also anonymous. Ideas were posted into the public domain and voted on but, the team didn’t want voters to be influenced by hierarchy. They wanted respondents to be honest.

‘I also was really, really pleased to see a clear desire – many, many ideas - on how we better share best practice. I think there is this undercurrent of concern that the world is moving along so fast and how the hell do we keep up with it?’ he says. 

‘For me, Clever Together is a way of democratising policy’, Freed says. ‘In public sectors we see a sort of announcement-like culture, a need to meet the target, which often means we miss the point.’

By way of a summary, Freed turns his attention to digital transformation. ‘The more I think about this, the more I regret using the word “digital” in building a digital-ready workforce,’ he says. ‘It’s really interesting, the way the word “digital” is used. ‘It divides people. It means hundreds of different things. And when I first talk to people about what building a digital-ready workforce really means, they all assume I mean being able to use electronic patient records or being able to use an iPad. And I don’t. What I really mean is being equipped to shape your own destiny.’

Image: iStock.com/alexey_ds