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For the past few weeks I have been helping co-ordinate our COVID-19 response in our NHS organisation which has been a huge task and a real emotional rollercoaster. The pace and scale of change in our organisation over the past weeks has been astounding.

The pace and scale of change in our organisation over the past weeks has been astounding

In my organisation, a mental health trust, we are behaving and working differently with respect to change. Our services have been re-designed to face the challenge of staffing shortages, new physical health needs and mental health effects of the COVID-19 pandemic. It took us 10 days from conception to opening a 24 hour Mental Health Emergency Department, we reduced bed occupancy from over 100% to less than 85% (previously a pipe-dream) and introduced virtual clinics and home working. We are far from unique and up and down the country transformation of all types of services are happening. All of this happened without a single business case.

This has made me ask the question, “What has changed to make change to happen so quickly?”

Firstly, it is important to say that none of the changes have been perfect. It is not clear whether what’s happened is offering a better experience for our communities and we do not know how safe the changes are. What is true, however, is that the resistance to change that seemed to burden those of us wanting to make change happen has all but vanished.

We have to acknowledge that much of the change is driven by fear and anxiety and it is not a sustainable situation

Often trying to get change to happen can feel like pushing against an immovable object and inertia can be a great demotivator.

Over the past weeks, I have experienced times of working with almost no resistance, like I was working in a gravity-free space, where a gentle force applied to change something accelerates quickly with the support from others. For anyone familiar with the work of Ralph Stacey and complex adaptive systems, the amplifiers of change ideas in networks have been very powerful and the inhibitory networks seem to be slumbering. I thought it was worth thinking about the shift in mind-set that has occurred.

John Kotter described the need to create a sense of urgency in order for transformation to happen. For many organisations, an existential crisis is needed. I think we can agree that we all share this sense of urgency and impending crisis. We have to acknowledge that much of the change is driven by fear and anxiety and it is not a sustainable situation. The risks of burn-out and psychological trauma are clear. Thankfully, awareness of staff wellbeing has been high on the agenda in many places.

Reflecting on some of these changes in my own work culture here are some thoughts:

  1. The Burden of Assurance and Governance has reduced. Many involved in QI feel strongly that the balance between assurance and improvement is tilted heavily towards assurance which can often be a real hindrance to change and a culture heavy on assurance can stifle creativity and motivation. Over the past weeks’ performance scrutiny, attendance at assurance meeting (which most people are loathe to attend and at least in my context do little to improve our system) and commissioner demands, which can cause discord, have disappeared. Released from some of the unnecessary scrutiny and burden people feel more confident and empowered to make change happen
  2. Reversal of accountability. In Crossing the Quality Chasm (2001) Don Berwick and others described four levels of healthcare – from patient/community/microsystem/organisation/environment – and I remember him expressing the view that we needed to shift the direction of accountability towards the patient rather than up-the-chain of command within the organisation. I think in some ways this has happened. I have noticed many examples of senior leadership shifting from directing/demanding, to asking “how can I help?” and working to solve problems or overcome obstacles. As in point one, this creates psychological safety, a key ingredient in the psychology of change.
  3. Shared purpose. There is an undeniable sense that we are in this together and people are working hard for each other and looking out for one another. I think the narrative around what is happening is so clear and undeniable and many people have reconnected with their own sense of purpose in what they do and why they do it. It also probably makes the fear and anxiety more manageable.

I am not trying to paint an overly positive picture. The pressures on our staff at all levels are enormous. But change is happening fast and people are being creative and innovative at a level I have never seen before. We would do well to try and understand some of the psychology behind this and how we can harness this in the future, hopefully not in the shadow of a horrible pandemic.

Find out more about Psychology 4 Improvement via the Q Exchange project page

You can also join the Psychology 4 Improvement Special Interest Group to stay up to date on the project’s work.


  1. Thanks for the blog Fredrik. Interesting to hear how you experienced the theory in practice, barriers diminishing, positive improvements being pushed through without seeking perfection and the sense of purpose holding everyone together. Wonder what we will learn when we look back that can be used in better times.

    1. Thanks for comment Louise - I am wondering how much we will be able to hold on to and how sustainable this is - lots of conversations about "what can we stop doing?" "what should we continue doing differently?" and "what have we stopped that we need to restart?"

      I hope we are able to keep some of the mindset going but that may be hardest thing

  2. Fredrik

    Your post is bang on the money. A great read and very though provoking. In Scotland we have been encouraging people to capture ideas, feelings;  what must we quickly disregard and what should stay and be ]improved for the future. One example is Scottish Rural Medicines Collaborative who are co-ordinating some systematic fee-back. he particular work I am supporting is in the move to remote video consultations where we have gone from 300 to 9,000 consultations per week over a month. Its called Near Me @NHSNearMe it was tested and used in NHS Highland over a two year period 2017 and 2018 with little interest elsewhere until Covid-19 came along. Part of the reason we responded in Highland is we had public protest about the long distances people had to travel for 5 or 10 minute appointments. I have done one blog about this for HF Q and should be another one being published next week. Maimie

    1. Hi Maimie,

      I heard about the great work in Scottish Highlands at International Forum and then Q Event which was really inspiring. Although we always talked about how useful this type of working would be our organisation never really took assertive action to make it happen until now - we use Attend Anywhere and I am now seeing patients using this which works super well and saves me lots of time and is safer for both me and the patient. Interestingly many of the people I work with are reluctant to use it and want to continue to see patients face to face.

      Reminds me a lot of Everett Rogers Diffusion of Innovation work and the reality that changing how people behave is hard work and is best done through good relationships and showing the benefits via people others find credible and work closely with! This is one of those changes that ticks many of the boxes for fast spreading innovations according to Rogers - relative advantage (yes), compatibility (true for most clinicians), complexity (using it is simple as platforms are really user friendly now), trialability (easy to show others how to use it), observability (yes).

      Look forward to your blog!


  3. Guest

    Christian Subbe 1 year, 12 months ago

    I would be curious in which terms the state of UK mental health services pre-COVID would be described if not with existential crisis? Is it not the perceived change in the speed of environmental adjustment that has dislodged inertia?

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