Beyond received wisdom and authorised accounts: what knowledge is needed to avoid repeating history?

Comment on “Attending to history” in major system change in healthcare in England: specialist cancer surgery service reconfiguration.

Why it matters

Something that occurs repeatedly in research in health policy is that the lessons of the past are forgotten. So-called ‘zombie’ ideas – ideas which are unproven or poorly evidenced – seem to never go away, while other ideas and policies that seem to be well founded are badly affected by poor implementation.

Systems seem to face difficulties in learning from the successes and failures of past change efforts. These problems may have their roots in many things, such as political inflexibility, managerial churn, and organisational amnesia—but addressing them effectively is a key challenge for improvement.

Official accounts of previous change attempts provide useful information about the processes that were followed. However, they may leave out information about the key relational and political factors that have the potential to derail the change process entirely.

Approach

We expanded upon the observations of Perry et al regarding the key elements of a successful healthcare system reconfiguration in Greater Manchester and discuss the most effective ways to account for history in leading change.

We looked at Perry at al’s argument that “attending to history”, by taking account of personal and documentary records and memories of previous efforts and service reform, supported those leading the reconfiguration of cancer surgery services, enabling them to reduce the impact of potentially challenging issues.

We also identified the need to see past the official accounts of previous change attempts and take account of local context and multiple stakeholder perspectives to achieve a fuller understanding of the lessons of the past.

Observations

Official accounts of change attempts lack important subjective information

Official records, for example, often omit or play down conflicts between individuals and groups, and how these conflicts may have affected earlier change attempts. Yet relational, emotional, and political factors influence how stakeholders in the present view both the events of the past and the current attempt at change. Failing to account for this may undermine the current change process, even when desire for the change exists across many groups.

Combining different forms of knowledge can assist a change process

In Perry et al.’s example, an internal consulting agency that facilitated cancer service reconfiguration had a key role, acting as an honest broker between different interest groups. Also key to this process was combining robust, proven change management techniques with intimate local knowledge. Understanding this local knowledge, including the background, politics, and interrelationships of the key stakeholders, proved essential to gain consensus and keep the project moving forward.

Change leaders should seek alternative accounts of previous change attempts

Effectively accounting for history means moving beyond official, dominant accounts of the past. Getting at ‘unofficial’ accounts of what happened can reveal crucial details, from concerns about the distribution of power among provider organisations to the personality clashes that need to be avoided. These accounts may offer a fresh perspective on previous change attempts that may not be apparent to those at leadership level. Likewise, the very act of looking for such accounts may make those key actors feel heard and valued, which can be helpful in securing their commitment to the change.