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Getting your idea to thrive in a complex system like the NHS

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  • Picture of Karen Fitzgerald FRSA
    Karen Fitzgerald FRSA
    Expert in Strategy Execution - health, sustainability, responsible business
  • Public Services & Communities
  • Institutional reform
  • Leadership

Leadership should focus on implementation over innovation.

That’s probably not a very popular message. I’m sure most people find it far more exciting to focus on the details of their idea than the specifics of how they are going to implement it. But failing to devise tactics that take account of the implementation landscape sees off many a good idea.

How to implement innovations successfully 

What are some of the factors that can lead to innovations being successfully implemented?

Research funded by Cancer Research UK into 8 separate NHS projects implementing various cancer pathway innovations offers some insight.

This research demonstrated that although the idea and context may be different, the factors leading to success are remarkably consistent:

  • building relevance
  • understanding emotions
  • thinking beyond your own team’s boundary
  • fostering a network of committed individuals.  

Request a copy of the full paper for further practical insights.  

Change in complex settings takes time

Change takes time. This is often another unpopular message, particularly with those at the ‘top of the office’. Yet most of us, if we are honest, know this to be true from our own experience. Why? Because of resistance to change.

Projects that were novel or involved multiple stakeholders spread across different teams and organisations experienced the most resistance.

As projects took steps to move forwards, they triggered the self-preservation reflex of the broader health system, which ‘pushed-back’ to maintain the status quo.

Leaders consistently underestimated how much of their personal time would be consumed by building relevance and securing commitment from key individuals - including navigating the aftermath of the occasional ‘hand grenade’ lobbed by individuals who were opposed to the idea.

How can leaders deal with this? One way is to be more realistic with timetables. Another is to spend more time up-front anticipating challenges and devising tactics to counter them.

Leading change is a relational activity

Being a leader who wants to create change is about relating to people. This might sound obvious, as most of the work of implementation revolves around coaxing people to do things differently, but it’s often forgotten. More intentional focus is needed on the emotional aspects of change.

How often do people ask themselves:

In what ways is this new idea going to go against some long-held value or way of working?

And then, how often do people take this into account when talking to those involved? (This is a particularly important question where it relates to serving the patient.) 

Some leaders have a natural aptitude for this. In our research, the ability to build trust-based relationships in difficult circumstances and to bring people together to achieve a common purpose were observed to be important leadership attributes. Both of these things take time.

In an NHS, where service delivery is distributed across multiple team boundaries and complexity is the norm, the case for adopting a relational leadership style would seem to be clear-cut. Our work suggests that the same principle would apply across the public sector.

Informal networks are core to successful change

One important way people can relate to each other is through informal networks.

Much has been written about how informal networks can be vehicles for change. Our research backs up this idea – strong local networks are important. There was no successful implementation of an innovation without a functioning network of enthusiastic and committed individuals to make it happen.

Longstanding networks were more likely to have consistent leadership and a history of innovating. Going from one success to another. For those leaders that had to build a network, this was a long and involved process, which took a lot of personal energy.

Given how often NHS structures change, the value of these informal networks in sustaining change is incalculable. They keep the NHS moving forwards, irrespective of the latest reforms.

Tend to implementation to create lasting change

We encourage leaders across the public sector who are serious about change to focus less on their innovation and more on nurturing its implementation. Try to think like a gardener. Worry a bit less about the seed, and more about tending the garden and creating the conditions in which it can grow and thrive.


Karen Fitzgerald is an RSA Fellow and leads a programme of service innovation at Cancer Research UK. She is passionate about re-thinking how things work to address systemic issues. Follow her on Twitter @changecurves


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  • This rings so true. As clinical lead for our Emergency Department for a few years, getting things done was absolutely dependent in informal networks. The value of this is incalculable but not sufficiently recognised or valued. The actual culture I experienced was one of protocols, standard operating procedures and a relentless attempt to clarify boundaries and simplyfy complexity, which in my view undermined sustainable change. The healthcare system is complicated and achieving meaningful lasting change requires a relational approach. You might hope that as healthcare is a 'People business' as individuals within healthcare, we have some inherent capacity to grapple with this. We will need to loose some of the overbearing unhelpful regulation and allow some blurring of boundaries between different services.

    • Nickie, I'm pleased the value of informal networks echoes your experience. And, there is something in your observation around relentless attempts to clarify boundaries rather than collaborating around something more 'whole'. Karen.

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