UoB 04021766

Leadership for Advanced Practitioners Module LEM 7011-C

Critically analyse the role of Advanced Practitioner in leading a change

Contents
Table of Figures 02

1. Introduction 03

2. Background 03

3. Preparing for Change; Selecting appropriate Change Models 04

(i) Lewin's 3 Stages of Change 05

(ii) Kotter's Eight Step Change Model 07

4. Implementing Change 08

(i) Analysing Leadership and Management Styles

(ii) Utilisation of Service Improvement Tools

5. Conclusion

6. References

7. Appendices

Appendix A: Abbreviations

Appendix B: CQC Inspection Report 2016?

Table of Figures Page

Figure 1: Factors affecting Change

Figure 2: Lewin's Change Model
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Figure 3: Kotter's Eight Steps
Figure 4: Comparison of Kotter’s and Lewin's change models
Figure 5: Root Cause Analysis
Figure 6: Force Field Analysis

1. Introduction

In the frontline of healthcare, the Allied Healthcare Professionals (AHPs) deliver patient care
in various settings; hospitals, surgeries and care homes. The role of AHPs is forever
developing and amidst the established roles, the emergence of new roles continues in
alignment with patient needs. The substantial responsibility of the education and upskilling of
these new roles, along with existing roles lies with Health Education England (HEE). 'HEE is
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responsible for ensuring that our future workforce has the right numbers, skills, values,
cultural sensitivities and behaviours to meet patients’ needs and deliver high quality care'
(HEE, 2017). Furthermore, the Department of Health (DoH) endorses that "HEE’s objective
is to develop a more flexible workforce that is able to respond to the changing patterns of
service.” (Mandate from Department of Health to HEE). It is therefore essential that a more
flexible workforce is developed to respond to the changing needs and requirements of service
users. One of the roles that has become increasingly popular is that of the practice-based
pharmacist. The role has evolved significantly as its widespread application continues to be
acknowledged. Practice based pharmacists are now more commonly taking the name of the
Advanced Clinical Practitioner (ACP) upon completion of necessary qualifications.

The role has developed partly to address demand and workforce issues. The National Health
Service (NHS) faces ongoing challenges; a rise in chronic disease, financial burdens,
recruitment issues and growing patient needs all are indications of the requirement for new
models of delivery of healthcare coupled with a flexible workforce. 'As well as building
capacity in our workforce, this includes the development of new and advanced roles and
innovative attitudes toward the mix of skills in teams. The current model of primary care is
unsustainable, and a new workforce is required to support primary care and community care.'
(Radford M, 2016)

2. Background

The majority of NHS care is provided by general practice and access to general practice is by
appointment only. Historically, patients have remained unsatisfied with the access to timely
appointments. The problems associated with access to timely appointments however, are not
localised to a particular region but extend to the National level. The NHS Five Year Forward
View has highlighted 'One of the public’s top priorities is to know that they can get a
convenient and timely appointment with a GP when they need one. That means having
enough GPs, backed up by the resources, support and other professionals required to enable
them to deliver the quality of care they want to provide' (NHS, 2017).

This study seeks to present a retrospective analysis of a change in practice, lead and
implemented by an Advanced Clinical Practitioner (ACP). It highlights the effective use of
the role of the ACP in leading the change. The ACP identified a need to improve patient's
access to timely appointments after a review carried out by the Care Quality Commission
(CQC) at an unnamed GP Practice. (here onwards identified as the Bradford Practice).

Following the inspection by the CQC, at the Bradford Practice (see report at Appendix B?),
poor patient feedback was identified in relation to the appointment system at the Practice.
Patients strongly felt that they were unable to get appointments and timely access and could
be waiting for weeks before seen by a GP. (Ref report). In light of this the ACP recognised
the need for a significant change in the appointment system in order to improve access to
healthcare at the practice. The ACP sought to introduce a 'Rapid Access Clinic’ (RAC) which
would essentially allow a specified number of additional same day appointments with the
ACP. The benefit of this was two-fold; increased access to appointments and effective
utilisation of the role of the ACP at the practice.

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The following sections of the study will explore the triggers of change and the various
Change models that were considered during the preparation stage; assess the leadership and
management styles as well as the service improvement tools deployed during the
Implementation stage, followed by a conclusion of the process.

3. Preparing for Change; Selecting appropriate Change Models

Roussel (2006) states that change can help achieve organisational objectives as well as
individual ones, and adds further that change should be 'purposeful, calculated and
collaborated'. It is therefore a crucial part of the process to understand the purpose driving the
change and to select the most appropriate model to implement the change. The context of the
change i.e. the factors that would affect the implementation stage, should be given due
consideration in selecting the appropriate change model. Figure 2 below summarises some of
the major factors that would impact the implementation of any change within an organisation.

Fig 1: Factors affecting the Implementation of Change. West, S (2017)

Generally, change takes place in 3 major stages; Preparation, Implementation and

Maintenance (i.e. sustaining the change), these form the backbone of a number of proposed
change model theories. The individual leading the change should consider following a known
change theory and customise this to their situation. A number of changes that fail to succeed,
do so as a result of poor implementation, therefore it is important to follow a structured
approach that suits the context of the change. When selecting the most suitable change model,
it is also advisable for the change leader to anticipate reactions to the change from all those
that would be impacted. This is a core factor in effective implementation of the change
process and more importantly, recognising reactions and managing these before the change is
implemented would mean that the change is more likely to be sustainable.

For the purpose of this study, two change models will be discussed and analysed in depth;
Lewin's 3 Stages of Change and Kotter's Eight Step Model. Regardless of which model is
used, in practice it is almost impossible to execute the model to perfection. There is no ideal
model for every situation, therefore it lies with good leadership to obtain the desired results
despite inevitable deviations from the model. It is essential to allow for some flexibility when
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following a model rather than following it too rigidly.

(i) Lewin's 3 Stages of Change

Kurt Lewin, a physicist used the analogy of unfreezing an ice cube to 'change' its form and
then refreezing this in its desired form, as shown in Fig.3. The model was developed in 1951
and since has become a cornerstone model for understanding organisational change. The
model is linear and therefore simple to apply. The stages of the model are more commonly
known as Unfreeze – Change – Refreeze, Lewin (1951).

Figure 2: Lewin's Change Model

By recognising the three distinct stages of change in Lewin's model, it is possible to plan the
implementation of the change required. The first stage is about creating the motivation to
change i.e. 'unfreezing' current practices and altering existing attitudes towards working
practices and preparing the ground. Effective communication about the proposed change is
vital at this stage if people are to understand and support it. In terms of applying this to the
change that the ACP would (prospective not retrospective - not sure about this) implement in
the practice, this would mean liaising with all the necessary staff to communicate the change.
The communication should clearly explain what has triggered the change (See section 1.2
above) and what form the change would take, i.e. in the form of the Rapid Access Clinic. A
clear action plan would be devised detailing intermittent stages with time scales and naming
those who would be concerned at each stage. This would include all fine details for example
what days and hours the clinic would run, who would run it, who would cover unplanned
absence, where in the practice it would run from, and how patients would be filtered for an
appointment at the RAC as opposed to an appointment with the GP. Furthermore, a clear
criterion should be defined for filtering the patients and staff appropriately trained in this
regard. Once the staff at the practice fully understand the change it would then be necessary
to inform the patients of the new approach before it is implemented. This stage of Lewin's
change model is beneficial as it allows the change leader to effectively plan and prepare the
process.

The second stage is about movement, i.e. making the change. At this stage it would be
necessary to empower the people to accept new ways of working and develop new
behaviours. At this stage it would also be appropriate to identify teething problems and
generate action plans to overcome these early in the process. In terms of the RAC, this would

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entail commencement of the clinic from the designated date. The staff involved in the process
would be reminded a few days in advance about the initiation of the clinic and any necessary
resources would be made available. Throughout this stage it would be ideal to identify and
review problems as they arise. Maximum flexibility would be needed in the planning and
implementation of the change. Lewin's change model does not actually offer a review process
which is a major disadvantage of the model. If the implementation of the change is not
reviewed for its failures and shortcomings then there is no opportunity to address these.

In the final stage of Lewin's change model, ideally the organisation returns to a sense of
stability and 'refreezes' in this new changed state. Stability is reinforced when the benefits of
the change are observed, as this creates confidence in the new state. In order to sustain the
RAC, the ACP leading the change would need to consistently promote a positive attitude;
acknowledgement and praise are essential factors in fuelling the final stage as on-going
approval of desired behaviours encourages stability. It is not until the change has become
incorporated into the culture, that it can be deemed frozen.

It can be seen that Lewin's model of change is ideal and simplistic. The fact that it is simple
and not too rigid means that each stage can be broken down into sub-stages that can be
customised to the individual/organisation executing the model. The major disadvantage lies
in its linearity, the model is not cyclical hence not promoting a 'review' or 'evaluate' stage,
however due to the flexible nature of the model, this can easily be incorporated by the change
leader.

(ii) Kotter's Eight Step Change Model

Dr. Kotter, a leadership expert devised a change model that he felt if followed, could help
organisations avoid failure and become adept at change. Kotter proposed that by improving
their ability to change, organisations could increase their chances of success, Kotter (2012).
The eight-step process has been summarised in Figure 4: Kotter's Eight Steps.

Figure 3: Kotter's Eight Steps

The first step in Kotter's eight is about creating an urgency for the change, for example by
providing evidence that suggests there is a need for change or by identifying a crisis
(Mourfield, 2014); the ACP could adhere to this step quite easily by providing statistics of the
number of patients declined appointments on a given day or alternatively using the CQC data.
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Following the first step, the second step is about forming a powerful coalition, i.e. bringing
the right workforce together to lead the change. The ACP at this step would need to identify
members of the team that would co-lead or assist in leading the change. This may be a GP at
the practice or the Practice Manager. Kotter's third step is about creating a vision for change
and to do this management should determine the values that are central to the change,
According to Kotter, step four, communicating the vision is all about, “using every vehicle po
ssible to communicate the new vision and strategies” (Kotter). Steps 3 and 4 are essentially
linked, at step 3 Kotter advises to create a vision and at step 4 to communicate that vision - in
practice the ACP would clearly develop a vision of the intended outcome (a successful RAC)
and then communicate how this would be achieved to the rest of the team. Step 5:
Empowering Action is a critical stage in Kotter's change model, at this stage the change lead
would not only identify anticipated challenges in the implementation but also devise
strategies to remove any obstacles that may arise. Empowering the people is also about
providing any necessary training and coaching. In terms of the RAC this would mean training
the staff to understand clearly the criteria for referral to the RAC.
Kotter's 6th step is about generating short wins. This is about acknowledging small benefits.
The ACP at this stage would identify small successes for example, fewer patients declined on
the day appointments or more time available for the GP to carry out other tasks in the
practice. Short wins should be communicated to the team to encourage their participation in
the change. Whilst doing so, it is imperative to 'not let up' and to avoid the risk of premature
victory, this is the essence of Step 7 where Kotter advises consolidation of gains and
producing even more change. The ACP would need to ensure that the short-term
achievements are built upon to maintain them and render long term success.
The final step of Kotter's 8 step change model is concerned with institutionalising new
approaches in the organisational culture, put simply 'making the change stick'. In practice, the
ACP would communicate the link between the new approach and widespread organisational
success. This is a vital part of the process. A guiding coalition alone cannot root change in
place no matter how strong they are. It takes the majority of the organisation truly embracing
the new culture for there to be any chance of success in the long term, Kotter (2012).
Kotter's 8 eight steps mimic Lewin's 3 stage model. A comparison of the two models is
presented in Figure 5 below, the first 3 steps being the equivalent of Lewin's first stage, the
next 3 steps are equivalent to Lewin's second stage with the last 2 steps resembling Lewin's
final stage.

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Figure 4: Comparison of Lewin and Kotter Change Models (ref PowerPoint)

4. Implementing Change

(i) Analysing Leadership and Management Styles

There is evidence that leaders who create change enhance the success of an organisation more
than leaders who manage change. Furthermore, when change is managed successfully,
members are participants in making positive change happen, the organisation experiences
higher morale, greater productivity and less job dissatisfaction (Bruhn JG, 2004). A good
change leader is therefore key in underpinning successful implementation. Over the years a
number of leadership styles and theories have evolved including The Great Man theory, Trait
Theory and Behavioural Theory.

The Great Man Theory is a famous 19th-century idea by the famous historian, Thomas
Carlyle. Carlyle proposed that history could be explained by the presence of many great men,
who were able to do so well simply due to their personal charisma and intelligence. Although
this had been disputed over the years and it has been believed that anyone could possess the
qualities of a great leader, evidence suggests that management scholars and organisational
psychologists now feel comfortable with the idea that some people-whether by innate
qualities, distinctive experiences, or some combination of both, simply have more than others
of this “right stuff” required for leadership Organ DW (1996).

The Trait Theory of leadership is in agreement with the Great Man Theory and suggests that
leaders are born and due to this belief, those that possess the correct qualities and traits are
better suited to leadership. This theory often identifies behavioural characteristics that are
common in leaders.

Behavioural Theory on the other hand implies that leaders can be made. As the name
suggests, the theory is largely focused on the study of specific behaviours of a leader. For
behavioural theorists, a leader behaviour is the best predictor of his leadership influences and
as a result, is the best determinant of his or her leadership success.

In terms of management styles, Rensis Likert (1967) proposed four types of management;
Participative, Consultative, Benevolent Authoritative and Exploitive Authoritative.

• participative – the leader trusts his subordinates completely, seeks and acts on their ideas
and involves them in setting goals
• consultative – the leader shows trust and confidence towards subordinates, seeks their
opinions and ideas, but retains decision making power
• benevolent authoritative – the leader has some trust in his workers but treats them in a
condescending and paternalistic manner
• exploitative authoritative – the leader has little trust or confidence in his subordinates,
manages by issuing orders and uses fear and punishment as motivators
Gonos G and Gallo P (2013).
As a newly qualified ACP, and also a new employee to the practice, the leadership styles that
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would best suit the ACP are either participative or consultative. The authoritative styles
would not be a wise approach as the ACP does not have an established good-working
relationship with the colleagues. Furthermore, the colleagues have maintained a well-run
practice for years and have a good rapport with the patients, hence they are in a good position
to be consulted. They will present valid rationale for the 'driving' and 'restraining' forces with
respect to the proposed change. In addition, Likert’s research suggested that consultative and
participative styles were generally more effective, although their success is based on
maintaining a high level of employee’s participation in management.

(ii) Utilisation of Service Improvement Tools

In order for the change in practice to be executed smoothly, as well as following an

established change model, there are a number of service improvement tools that are available
to support the change process. These include but are not limited to the following: Root Cause
Analysis, Process Mapping, Force Field Analysis, Six Sigma, Theory of constraints, The 8 Wastes and
Business Process Engineering. The service improvement tools deemed relevant to the change
proposed by the ACP have been discussed in further depth.

The change was a planned change which means it was a conscious and reasoned decision.
The ACP felt the need for a change in practice that was motivated by several factors. This
means a Root-Cause Analysis can be done to identify the causes of change. As previously
noted, the primary trigger for the change was the poor patient feedback from the latest CQC
inspection. Public demand for same-day access to general practice is also well documented
through the GP patient survey. The latest survey results showed that 40.4 per cent of patients
who contacted their practice for an appointment wanted to see or speak to someone on the
same day, with 9.9 per cent wanting to see someone the next day and 23 per cent in a few
days, Baird et al (2014). Patient feedback at the Bradford Practice also indicated that a
number of patients who were unable to obtain a same day appointment accessed out of hours
services as well as emergency services, with some even requiring admission in hospital.

A lack of General Practitioners at the Bradford Practice also prompted the need for a change.
With only one full time employed GP it was extremely difficult for the appointment demand
to be fulfilled hence it was highly appropriate to utilise the ACP already working in the
practice to support the GP in meeting the demand for on the day appointments. In 2015,
Professor Rolan, Chair of The Primary Care Workforce (set up by HEE), advised in his report
that a broader range of staff should be involved in providing care and set out how the talents
of the wider workforce can be better deployed to reduce the workload burden on GPs, meet
patients’ needs and to free GPs up to do what they do best, Roland M (2015). A summary of
the causes of the change have been presented in Figure 1: Root-Cause Analysis which shows
the triggers that motivated the change and the anticipated benefits of implementing the
change.

Change Triggers Benefits of Change

Increased demand for on the day
appointments
Increased pressure on GPs
Increased no of patients accessing
out of hours and emergency services
Demand met/reduced through additional appointments
Reduced workload allowing better use of GPs time
Reduced burden on out of hours and emergency services
(thus reducing NHS costs)

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 Shortage of GPs Effective use of ACPs

Figure 5: Root Cause Analysis

The Theory of Constraints is a philosophy of management and continuous improvements

concepts developed by Dr. Eliyahu Goldratt as introduced in the landmark book "The Goal',
(Goldratt E, 1984). In a nutshell, the idea behind the theory is that the most limiting factor in
a process or achievement of a goal is identified, and quite simply a systematic approach is
developed to remove the ‘constraint' until it is no longer limiting the process. The idea is
common in manufacturing processes where constraints are more commonly termed
'bottlenecks' (Bates S, 2013). For the ACP, the theory has already been applied by the
decision to introduce a change. The 'goal' would be to make more 'same day' appointments
available to see more patients. The major constraint, or hinderance is the lack of practitioner
and in order to remove the hinderance a new practitioner/clinic is proposed.

Kurt Lewin who developed the 3-step change model devised his own service improvement tool knows
as the Force Field Analysis. The tool simply identifies the factors for and against change. Nash and
Young (2008) advise that the tool 'helps you look at the big picture by analysing all of the forces
impacting on the change and weighing up the pros and cons. Having identified these, you can then
develop strategies to reduce the impact of the opposing forces and strengthen the supporting forces'.
Forces in support of the change are also called ‘driving forces', whereas forces that work against the
change are called ‘restraining forces'.

Guidance from Lewin's (1951) force field analysis demonstrates the complexities of the change
process and how driving and resisting forces were incorporated within the planning and
implementation phases, Baulcomb JS (2003). Figure 5 below shows an application of the Force Field
Analysis tool by the ACP in the example of the RAC proposal.

Figure 6: Force Field Analysis of introducing an RAC at the Bradford Practice

Conclusion

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References

Baird B, Charles A, Honeyman M, Maguire D and Das P (2014) The King's Fund:
Understanding the pressures in General Practice

Bates S, (2013) Advanced Manufacturing Methods Department of Technology, College of

Engineering
Baulcomb JS, (2003) Management of change through force field analysis

Bruhn JG, (2004) Leaders who create change and those who manage it. The Healthcare
Manager, Vol 25

Gonos J and Gallo P (2013) Model for Leadership Style Evaluation. Management, Vol 18

HEE (2017) Website accessed 22/12/17 at https://hee.nhs.uk/

Kotter, JP (1996) Leading Change: An Action Plan from the World's Foremost Expert on
Business Leadership Harvard Business Press

Kotter, JP (2012). The 8-Step Process for Leading Change accessed at RBS Group Change
Management at www.rbsgroup.eu

Mandate from DoH to HEE accesses online at https://www.gov.uk/government/uploads/

system/uploads/attachmentdata/file/310170/DH_HEE_Mandate.pdf

Mitchell, G (2013) Selecting the best theory to implement planned change

Mourfield R, (2014) Organisational Change: A guide to bringing everyone on board.

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Postgraduate Thesis, Indiana University
Nash, R and Young D, (2008) Quality and Service Improvement Tools; Force Field Analysis.
NHS Institute for Innovation and Improvement
NHS (2017) Next Steps on the NHS Five Year Forward View accessed at
https://www.england.nhs.uk/wp-content/uploads/2017/03/next-steps-on-the-NHS-five-year-
forward-view.pdf

Organ, DW (1996) Leadership: The Great Man Theory Revisited. Business Horizons, Vol 30

Radford M, (2016) Advanced Clinical Practice: defining the future forward role HEE

Roland, M (2015) The future of Primary Care; creating teams for tomorrow. Report by The
Primary Care Workforce Commission, HEE

Roussel, L (2006) Management and Leadership for Nurse Administrators

West, S (2017) Leadership for Advanced Practitioners (PowerPoint Presentation) accessed at

University of Bradford Blackboard)

Appendix A: Abbreviations

ACP Advanced Clinical Practitioner

AHP Allied Healthcare Professional

CQC Care Quality Commission

HEE Health Education England

NHS National Health Service

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