In the last five years, United Kingdom has experienced a significant change in its national health services (NHS). This paper therefore focuses on that change. The first section is a detailed description and the main objective of the change. Using appropriate models and frame works, the second section identifies the key drivers to the change and how their interaction has affected the issues addressed by management. Drawing upon the examples of best management practices, the third section assesses the appropriateness of the approach taken by management in effecting the change and how effective management implemented the change strategy. The final section examines the extent to which the change has been successful in meeting its objective and assesses the need for any further related change.
2. Organisational change overview
2.1 The National Health Service
The National Health Service (NHS) is the public funded health care system in the United Kingdom (UK) that provides the majority of health care to the UK residents. Its areas of health care coverage are the primary health care, in-patient care, long term health care, ophthalmology and dentistry. The Department of Health (DOH) headed by the Secretary of State of Health is the UK government department that is responsible for the NHS (Department of Health 2007).
2.2 Major change in the NHS
Since 2005, the United Kingdom’s NHS (UK NHS) has been implementing an innovative technology that will help patients stay healthy and maintain their independence. This technology is targeted at terminally ill patients with long term health condition that require regular monitoring. It also covers elderly people suffering from dementia and individuals with Down syndrome who may be at risk of injury. Thus, with this new technology, patient’s emergency room visits as well as unnecessary nurse visits to patients’ homes are reduced. Furthermore, this technology increases clinical efficiency and reduces the mounting financial cost of institutional health care in the UK. The implementation is said to be the world’s biggest trial of remote monitoring of chronically ill patients in their homes. Patients in New Ham, East London and Hull Yorkshire have benefited from this programme.
This programme, funded by the department of health is been implemented by Philips, the world’s leading electronic companies. Philips electronics is hoping to prove to the NHS that it can immensely reduce the financial burden of institutional health care by implementing ultra-modern diagnostic equipment that uses internet technology to link patients from their homes to care providers in the hospitals. Since over 14.5 Million people in Britain have long term health conditions, it is expected that they will require regular monitoring (Department of Health 2007).
I am a trained Electrical Engineer and have been providing tele-health equipment installation consultancy for Philips UK since 2008. I am directly involved in the implementation going on presently in Hull and New Ham. Patients in New Ham and Hull are been monitored at Home using diagnostic equipments linked via broadband internet connected to local hospitals and clinics. These patients are able to use the diagnostic equipments to take their vital signs and blood sugar level. Subsequently, the information is wirelessly uploaded to patients TV for their own monitoring and electronically sent via broad band to staff at the primary health trust.
Further implementation is underway in Cornwell and Kent and will gradually expand to all cities in the UK as the department of health targets technology efficiency that could save the NHS Millions of pounds.
Although the technology enables people to live independently in their homes, it is not intended to replace hospitals and care homes but to make better use of recourses and reduce financial burden on the system.
3. Drivers for NHS change
Force field analysis by Lewin (1951) is a diagnostic tool used in looking at the variables involved in determining whether organisational change will occur. Once change priority has been agreed, a force field analysis can be used to identify actions that will enhance or deter their successful implementation.
Applying Lewin’s force field analysis as shown in figure 1 below, it can be seen that the NHS Tele health technological implementation has some internal and external driving and forces.
3.1 Internal Drivers
Among the strongest internal driving forces as can be seen in figure 1 below are; strong leadership and the need for accurate and consistent patients information availability. Strong leadership and commitment of top management are often cited as the most important factor for implementing a successful change programme (Bashein et al, 1994). NHS leadership is effective, strong and was able to provide a clear vision of the change programme.
Other internal driving forces are the fact that the technology will aid patients to be independent and free up nurses and doctors to concentrate on other important task. This motivated medical practitioners in looking forward for the change.
3.2 External Drivers
The identified external driving forces as can be seen in figure 1 are Government’s desire to reduce the cost of administering health care in the UK, New European Union legislation in support of tele-montoring and the recent economic recession. Since 2005 the UK government has been researching on ways of bringing down the cost of instructional health care. Limited resources availability as a result of the recent economic down turn and an increasing UK population has necessitated the need for a cost effective alternative as the status quo is unsustainable.
Another external driver is the new European Union legislation in support of tele-monitoring.
Figure 1: Lewin’s Force Field Analysis of health care change in the NHS
Strong leadership and shared goal across the NHS
Accurate and consistent information availability
Free up nurses and doctors to concentrate on other important task.
Government’s desire to reduce the cost of administering health care in the UK
European Union legislation in support of tele-monitoring
The recent economic down turn necessitating the need for fiscal responsibility
Adapted from Lewin (1951
4. Main objectives in making the change
4.1 Reduce cost of administering health care in the UK
As the case load in primary care in the UK is increasing in size and complexity and the number of people with multiple long term disease is also increasing, there is increasing financial burden of administering primary care in the UK. The tele-health technology will in the long run help to reduce the mounting financial burden of institutional care.
4.2 Reduce nurse visits to patients’ house.
Prior to the implementation of the tele-health technology in the NHS, each patient with long term condition is assigned a care taker nurse who’s duty includes regular house visit. The nurses are required to take patient’s vital signs, blood sugar level and other related data that are necessary in monitoring the patient’s health condition. Upon implementation of the tele-health technology, the required data are taken by patients and are automatically sent via the internet from patient’s house to the hospital through the diagnostic equipment. As a result, nurse visit to patient’s house is considerably reduced.
4.3 Maintain patients independent.
The technology ensures that nurses only visits when it is necessary and as a result allows patients to leave more independently. From a medical point of view, it is usually helpful for patients to be independent as it can give them the agility they may need to remain healthy.
4.4 Reduce patient’s emergency room visits.
As patient’s health situation is monitored on a daily base, doctors and nurses are able to know when a patient’s condition is deteriorating and therefore avoid emergency situation. In Hull and New Ham it has been noticed that emergency room visits by monitored patients is much reduced.
4.5 Increase in clinical efficiency
The diagnostic equipment interacts with the patient through a user friendly interface. It provides reminders, collects vital data and asks questions that help assess the condition of the patients. It also gives warning when a patient’s condition is changing. This in general allows doctors and nurses to intervene more quickly and accurately and as a result increases the overall clinical efficiency.
6.0 How action required was planned
Management tools for problem analysis are very crucial for success in change management. One of such tools is the ‘Cause and Effect’ analysis. ‘Cause and Effect’ analysis is also referred to as the Fishbone diagram because the diagram has a fish bone appearance. The technique was proposed by Ishikawa in the 1960’s and as a result called the Ishikawa diagram. The diagram is used to determine the root cause of a problem and identify areas that changes can be made. (Ishikawa 1985)
In applying the ‘Cause and Effect’ analysis to the NHS in determining what change is required and what action is to be taken. The first step is to get a clarity and consensus on what the problem is. Among many others, the focused problem statement identified in the NHS is the mounting financial burden of institutional health care in the UK. The economic recession and increasing overseas debt is forcing the UK government to look for ways of cutting cost and saving money. This necessitated the need for fiscal accountability and cost cutting in the NHS (NHS Centre for Reviews and Dissemination 2008).
In constructing the Fishbone diagram for the NHS, the problem statement forms the head of the fish bone alone with the fish backbone as illustrated in the figure 5 below.
The next step is to brainstorm potential causes of the problem. The major causes are laid out as large bones connected to the backbone. In the NHS, the major causes identified as responsible for the increasing financial burden are staffs people, technology, procedures, and policy. The fish bone diagram is then developed based on the identified causes.
The final step is to probe deeper into each cause. A question asking-technique included in Senge et al (1994) ‘Five Ways’ model can be used. It involves asking repeated ‘why does this happen’ until it is clear that the root cause have been found. The answers are then added as sub-bones to the cause as shown in figure 5 below.
Fig. 5 Fishbone Diagram stage three
Too many admin staffs
Increased number of nurses
Too many Doctors
Increased ageing population
More sick patients
More hospital admissions
Expensive medical equipment
Increased drug prescriptions
Pay increase by government
Increasing fixed cost
Mounting Financial Burden of Institutional Health Care.
There is increased spending in the NHS as there are now more people been treated in the hospitals than ever before. This is the direct consequence of increase in population and immigration over the years. Increase in the number of sick people and the ageing population has also contributed to increase spending. These increases in people requiring attention have necessitated an increase in Nurses, GP consultations and a large increase in drugs prescriptions. (Slywotzky and Morrison 1997)
Furthermore, pay increases offered by the government to medical practitioners were in many cases over generous. Economic inflation and increased cost of fix asses has in no little way affected NHS budget. The office of the national statistics (ONS) has shown that NHS productivity is falling as spending is increasing.
As output has not kept pace with rise in spending it is important to implement an efficient and cost effective way of administering health care. As the tele-health technology will ensure that the increasing number of people requiring health care is efficiently covered with little resources, it will therefore provide an efficient and cost effective way of administering health care in the UK.
Looking at it critically, it is important to know that cause and effective relationship may not be easily apparent and that an intervention in any part of a health care organisation will have outcomes in many others, not all of them anticipated, and not all of them desirable. Smith (1995a; 1995b) in his work on response to performance indicator highlighted that change can lead to unanticipated and indeed dysfunctional consequence.
Additional technigues that was used.
The NHS employed process modelling technique in order to gain understanding of how the current process works and provide a clear articulation of how the new process is to be different. The process modelling technique provided clarification of the expected process so that the NHS is able to plan the required action.
Fig. 6 Current and expected process flow
Current process flow Expected process flow
Is he in the clinic?
Doctor decides that a patient needs monitoring
Specialist nurse visits patient for information and counselling
Vital information register created for patient and care nurse assigned to patient
Care nurse visits patient and takes vital readings
Vital readings recorded in patients information register
Doctor assesses patients register
Necessary actions take for abnormal readings
Process repeated daily
Is he in the clinic?
Doctor decides that a patient needs monitoring
Specialist nurse visits patient for information and counselling
Tele-Monitoring equipment is install and doctors assesses patients information remotely
Necessary actions take for abnormal readings
The process flow in fig.6.0 above is a diagrammatical representation of all the staged involved in a patents monitoring task. It shows both the current and process and what the process is expected to be after the implementing the tele-health system. The current process requires 9 steps and would take between 12 to 24 hours to complete a cycle while the expected process will require 5 steps and would take 10 minutes to complete a cycle.
With the process modelling technique, the NHS identified that in order to successfully implement the change; it must fundamentally re-think the way work is done and adequately prepare the organisation for change.
How management implemented change
Having understood the situation, knowing why change is needed in the NHS, who and what needed to change, it is important to examine how these insights and what framework can be used to deliver the results that are needed.
The technique of Business Process Re-engineering (BPR) is employed in the NHS in order to implement the change that is needed. Davenport and Short (1990) defines BPR as a technique for redesigning the way work is done. They also stated that it enables organizations to rethink work process so as to improve customers satisfaction, reduce operation cost and become more competitive. In addition, Hammer and Champy (1993, p32) stated that ‘BPR is the fundamental rethinking and redesigning of business process to achieve dramatic improvement in cost quality service and speed’.
In the health sector, Walston and Kimberley (1997) observes that over 60% of hospitals are involved in re-engineering initiatives. In the NHS, the re-engineering initiative of the tele-health system is focused on optimizing productive work time, automating process to increase productivity and quality and resource management. The steps that were employed to implement BPR in the NHS are show in the model below.
Fig.6 Change process model
Communication the need for change
Effective communication is considered a major key to successful BPR change implementation (Jackson 1997). The NHS implementation process began with series of meetings between the NHS management and stake holders inside and outside the HNS that would be involved in the change process. The purpose is to communicate the need of the change and the technology that would be implemented to effect the change. The meeting also helped to ensure patience and understanding of the structural and cultural change that are needed. Cooper and Markus (1995) suggest that communication should be open, honest, clear and in both direction between those in charge of the change initiative and those affected by them. Effective communication continued in the NHS throughout the change process. This formed the base that prepared the entire organization for change.
Preparing the organization for change
Hammer and Champy (1993) stated that organizational culture is a major factor to consider in preparing for a successful BPR implementation. Organizational culture influences the organizations ability to adopt to change. In the NHS, management ensured that the organization can understand and can conform to the new values and management process that are created by the newly re-designed process. This is so that a culture which upholds the change is established. Benjamin and Levinson (1993) argue that preparing the organization to respond positively to BPR related change is critical to success.
In preparing for change, the NHS ensured that adequate trainings were given to staff that are involved in the change process. The New Ham University in conjunction with tele-health engineers from Philips UK provided the required trainings to staff. This is in line with the suggestion made by Tower (1994) that training and education is an important component in preparing an organization for change. Bruss and Roos (1993) also state that IT skills and techniques are important dimension of training for BPR.
Fundamentally rethinking the way work is done
After identifying and analyzing core business process, the NHS was able to define key performance objectives and design new processes to achieve the objectives. Davenport and Short (1990) define a process as a set of logically related tasks that are performed to achieve a defined outcome. Patient monitoring involves process with a great number of intermediate steps.
The objective of the NHS is to reduce the processes involved in to single process that takes part directly to the final outcome. The single process designed with the needs and wants of patients in mind will allow the NHS to gain important advantages in the following ways; It reduces process steps and the time it takes to accomplish task; Improving the accuracy of patients medical information; Eliminate human mistake inherent with complex and repetitive task; Improve NHS efficiency and effectiveness and drastically cut down the overall cost of health care
Implementing new technology to achieve change
In order to make changes, certain known elements are required Harrington (1991). These are elements that act as variables for processes to change. Thus, , adequate IT infrastructure is considered as a vital factor in successful BPR implementation Moad (1993). Also, identification of enabling technology for redesigning business process and proper installation of IT components contributes to building an effective infrastructure for business process Barrett (1994) .
In the HNS, the IT based tele-health system aimed at people with long term condition is the enabler for achieving change. The equipment connected to users television allows user to measure their vital signs. The results are automatically sent over the internet to monitoring centre. The results are monitored daily by health care professionals who can take immediate and appropriate action if there is any abnormality in the result. The system is designed to be user friendly, clear and straight forward.
After installation, the technician will go through the system with the user to explain how it works and how to use it. Users are also able to call the monitoring centre at any time should they have any issue with the system.
Extent to which change was successful
Despite the significant benefits gained from the successful implementation of BPR, it is noted that not all organization embarking on BPR projects achieve their intended result. Hammer and Champy (1993) estimate that as many as 70 percent do not achieve the dramatic result they seek. This in most cases is attributed to poor implementation of BPR rather than a problem with the concept itself. Implementation process is complex and needs to be checked against several factors to ensure successful implementation (Alter 1994).
However, it is important to note that the process re-engineering change initiative in the NHS can be said to be successful as it has implemented a modern technology which can be the way of the future for in-home patient care in the UK. It has helped increase productivity through reduced process time and has also drastically reduced cost. It has also improved quality and greater patient satisfaction in the NHS.
Comparing the periods before and after implementation of the tele-health technology in the NHS, there has been a reduction in GP and Nurse Visits to patient and also a reduction in hospital admission of patients with long term condition. General satisfaction with the tele-health technology and the use of the equipments is high for all groups of patients. Patients felt comfortable using the technology and did not find it difficult. They also felt it helped improved the awareness of their condition (Department of Health 2009).
To the 1.75 Millions who now rely on the tele-health service in the UK, it offers peace of mind and the certainty that there is always someone to help them in times of difficulty.
Resistant to change in the NHS
Johnson (1992) in his cultural web model shown in fig 6 below suggests that until the paradigm at the heart of culture is changed, there will be no lasting change. Based on Drennan (1992) definition that ‘culture is how things are done around here’ it is a general believe that organizational culture is a very strong resistant to any change implementation program.
Figure 6. Garry Johnson Cultural Web
In the NHS, evaluation has shown that the central principles of BPR – radical, revolutionary approach to change is fundamentally incompatible with the traditions, culture and politics of the NHS. This in no small measure is a major resistant to change in the NHS (Buchanan 1997).
Threat to Status
One of the resistant to change in the NHS is that many of its staff perceived the change as a threat to their personal position. This is in agreement with Hanner and Champy (1993) who argued that the fear of job loss by employees is a major resisting factor to the success of management change program.
Dawe (1996) added that, change moves the whole organization as well as every single employee out of their ‘comfort zone’ and as a result, there are always going to be some people who would try to resist the change process. This is true for the NHS as some of both its management and medical staff try to stop or ignore the process of change. This is because the management failed to make a compelling case for change to its staff. Some NHS employees believed that the change was initiated only for the sole aim of saving money and cutting cost, that there is nothing in it for them. As a result they were not motivated to support the change process. This is supported by Kotter (1998) when he suggests that failure to create a win over hearts and minds will reduce the impact of a change program.
Another major resistant experience in the implementation of tele-health change program in the NHS is fact that some people for personal reasons do not like to be watched over. They did not welcome the idea of been monitored on a daily base as they felt it violate their privacy right. The NHS management was able to resolve some of this problem by identifying patients who has indicated such fears and assuring them that only authorized medical officials would have asses to their information and that monitoring was mainly for their own good. Patients who were still skeptical and would rather not want to be monitored were all together exempted from the program.
Recommendation for future improvement
The overall improvement in patient health condition and reduction in hospital admission observed after implementing the tele-health system in the NHS supports continuation and further improvement of the scheme.
A recommendation for further improvement is that the NHS could develop an assessment and measurement system that would help to register the build-up of momentum and identify early victories. Success in management is of little value unless they are supported by best practices and hence Senge (2003) suggest that success depends on the application of best practice.
Nelson et al (1998) argues that although measurement is essential if change are to be sustained, the measurement them self must be defined practically. In the light of this, the NHS could adopt outcome and cost measurement, qualitative and quantitative measurement and a balances set of process to build measurement into the daily work routine and display it so that it tell a story of where they are, where they should be and where they are going in the change process.
Furthermore, the management of the NHS should be aware that resistant is part of the change program and that anticipation and planning for resistant is important in implementing a successful change program (Clemons 1995).
It is observed that the NHS management communicated change information only to stakeholder that was directly involved in the change program. This was only able to disfranchise the other stakeholders and strengthened the resistant. It is important that communication with a wide range of stakeholders directly or not directly involved in the change program be made so that they become involved and motivated (Stanton et al. 1993).
The major future challenge that the NHS may encounter is how to engender a culture of continuous change in which change is on-going, evolving and cumulative. It would require a major shift in assumptions made by the organization and its members. Many of the individuals and groups whose assumptions and behaviors must change if this cultural shift is to be achieved are perceived to be of high status and are used to the exercise of individual and professional autonomy.
As people are living longer and there are more and more people who are unwell, going into residential and nursing home and living with long term conditions, the NHS which is the public service most valued by the British people must be able to keep pace with these change in society.
The Remote monitoring tele-health technology will enable the NHS to effectively cope these increases in demand for health care. It would also help to reduce the overall cost of administering institutional health care in the UK.
Although there are still pockets of issues and resistant, the program is generally termed as successful as it is already yielding the desired objective of improving life and saving cost.
This paper presented an analysis of the approach take by management to effect the change and how effective management implemented the change strategy. It also demonstrated the extent to which change was successful and made recommendations for future development.
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