Healthcare Leadership with Political Astuteness and its role in the implementation of major system change: the HeLPA qualitative study

Clarifying the concepts of organisational politics and power

It is far beyond the scope of this report to summarise the extensive literature on social power. However, the close connection between the terms ‘politics’ and ‘power’ requires some clarification, especially given that the terms are often used together in the wider health services research and policy literature. As noted, these terms are typically used to refer to forms of influence and power that operate beyond the statutory or formal institutions of government or policy-making, and instead focus on the informal relations of influence and power that are dispersed throughout and across the organisation of public services. 54 For some, micropolitics is a form of ‘soft’ interpersonal power,35,37,42 whereas for others it reflects ‘deeper’ ideological or structural interests. 17,55,56 For the purpose of this report, four perspectives are highlighted as relevant to the study of organisational politics in health and care services.

The first perspective treats power as an individualised resource or behavioural capability that usually resides within an individual and that is enacted over others through episodic forms of influence, persuasion or coercion. This can be through direct interpersonal influence or indirect forms of agenda setting or opportunity framing. This view is common within the predominant conceptualisations of political skill found within the management studies literature,53,57 in which ‘person A’ influences ‘person B’ based on their political skills. The second view develops this episodic viewpoint by attending not only to the capabilities or skills of individuals, but also, more importantly, to the relational interplay between social actors. From this point of view, social life is organised through the ‘interactive order’ that emerges from the relational patterns through which people make sense of themselves and others. 58–61 The third perspective focuses on the relative position of actors within a wider social field of relations. 62,63 This recognises that people hold variable and unequal positions within social settings, which is reflected, for example, in their access to certain roles, resources and relations, and also their acquired preferences, dispositions or viewpoints. These condition or shape a social actor’s inclination and opportunities to act or engage in both change processes and organisational politics. This dispositional power is derived less from an individual’s skills or abilities and more from the structured opportunities to act reflective of their acquired dispositions and forms of social, cultural economic and symbolic capital. 63 The fourth perspective sees power as more systemic, ideological or discursive. Rather than residing in people, power flows through the relationships between people, and these structured relationships are reflective of broader structural interests or ideological imperatives. On one level, this represents a hegemonic form of power55 in which actors may not be entirely conscious of the interests that structure their lives. On another level, it suggests that the ‘micropolitics’ of everyday life are shaped or constituted by broader social and political discourses that are manifest in bodies of knowledge, social institutions and other apparatus of governing. 64

These different perspectives span the structure/agency divide within the social sciences for which, at extremes, research emphasises either the voluntaristic behaviours of autonomous actors or the determinism of social structures, institutions and ideologies. 65 Without reducing analysis to either structure or agency, this study developed an integrative view of organisational politics in which the different forms of power and influence co-exist across different analytical dimensions while still being connected and influencing each other, and without reducing analysis to one over the other. For the study of health-care organisation, this means paying attention to the structural interests that shape health policies,17 the institutionalised forms of power associated with certain professions,66 and the prevailing biomedical and economic rationalities that constitute modern health care. 67 It also means recognising that health-care professionals not only engage in interpersonal relations from the discursively constituted social positions within the field of health-care organisation, but also can act both within and beyond these positions in their day-to-day episodic interactions and negotiations with others. 68,69

It is worth recognising from the outset that, although the literature on organisational politics often recognises that power and influence operate across and between multiple dimensions, the literature of political skill and, to some extent, political astuteness tends to focus on the more behavioural aspects of political influence. That is, it focuses on the capacity for individuals to exert influence over others, typically based on their particular skills or abilities. Although this influence is seen as inherently relational and interactive, the unit of analysis often remains the individual, which means that the contribution or contingencies of wider social and ideological factors can be downplayed or overlooked. This study took the concepts of political skill and astuteness as its primary conceptual and analytical focus because these afforded a discrete empirical focus from which to contribute to the health services research literature on the implementation of change, and also because they offered a more focused and practical basis for informing leadership development. This meant, however, that some of the wider conceptions of power and politics were not directly or explicitly operationalised or applied in the conduct or reporting of this study, primarily for the purpose of analytical clarity.

Review 1: a ‘review of reviews’

A preliminary scoping review showed that a number of recent systematic literature reviews on the concept of political skill had been published in the last 10 years. 43 For this reason, a ‘review of reviews’78 was carried out to (1) identify and synthesise the main theories and frameworks, (2) clarify the conceptual and theoretical assumptions informing these frameworks, (3) identify the different methodological approaches and (4) determine how political skill is both acquired and used in different strategic contexts.

Review 2: a review of ‘political skill’ in health services research

The second review aimed to understand how the concept of ‘political skill’ or associated concepts have been used in the health services research literature, especially research investigating the implementation of organisational and system change. The review investigated (1) how the concept is defined and operationalised in the health service research, (2) what methods of enquiry are used to study political skill, (3) what the concept contributes to the study of organisational change in health services and (4) to what extent the concept offers distinct or novel analytical insight into the wider social science literature. Unlike the first review, this was inclusive of primary sources and was not limited to review papers.

Methodological approach

The interview study followed a narrative approach to investigate how people experience and make sense of their lives in the form of stories. 80,81 The telling of stories involves organising experiences in ways that make them comprehensible to the narrator and the audience through forms of ‘emplotment’, that is, when events are connected together in a way that conveys meaning and order. These stories reveal underlying assumptions, beliefs and values. The interpretation of these stores surfaces the meanings that actors hold while still recognising that these stories are being told to a particular ‘audience’ for a given purpose. 80–84

Sampling and recruitment

Sampling aimed to investigate service leaders’ experiences of acquiring and using political skill within and across different care sectors (health and social care), organisational types (primary care, acute and community), strategic and operational arenas (senior management and delivery teams), professional backgrounds (medicine, nursing and pharmacy), career stage and regional contexts. A purposive sampling approach was adopted in which participants were recruited on the basis of exploring one or more of these differences. 85 In addition, people were recruited who were currently participating or had recently participated in leadership training programmes, to investigate how aspects of political skill are addressed in current training programmes.

An initial sampling frame was populated by members of the research team based on existing research connections and knowledge of prominent service leaders and professional representatives. In addition, opportunistic sampling of service leaders occurred during research engagement activities, for example conference attendance. Over 80 people were identified, all of whom were categorised to inform representative sampling decisions in terms of their professional background, occupational role, organisational affiliation and geographical location. All of the identified people were contacted in writing to seek their participation, resulting in 50 participants.

Two strategies were used to identify and recruit people enrolled on, or who had recently completed, leadership training programmes. First, and following attendance at the 2018 Health Services Research UK annual conference, contact was made with the professional network for NHS leadership and management trainees, who issued an invitation on behalf of the study to over 40 people, from whom five people were recruited. Second, the academic leads for two postgraduate leadership development programmes distributed a similar letter of invitation to their respective learner cohorts. This resulted in three people agreeing to participate in interview, while eight learners from one programme offered to take part in a focus group. In total, 16 ‘trainees’ were recruited.

In total, 66 people participated in either qualitative interviews (n = 58) or a focus group (n = 8). In terms of demographic composition, the sample included 37 females and 29 males: 59 were white British, four were Asian or British Asian and three were black or black British. In terms of career experience, the sample was categorised into three groups: 10 people with < 10 years of experience, 23 people with 11–20 years of experience and 33 people with > 20 years of experience. It was not possible to determine the career length for 12 participants because the information was not given or they had multiple career changes. Of the 16 ‘trainees’ recruited for interview or a focus group, six were within the first 10 years of their career, with the other 10 being in established professional positions (eight in quality improvement and two in general management).

Participants were recruited from different health and care settings, although the majority were based in the acute hospital setting. Five were significantly involved in STP leadership and had ‘dual roles’ both with their primary NHS employer and in the management of a STP. Three people were recruited from the social care sector and one from the police services on the basis of having a significant role in health-care planning (Tables 1 and 2).

Data collection

Narrative interviews invited participants to reflect on and talk about their experiences of organisational politics and political skill in the context of their involvement in health service change. A preliminary interview topic guide was developed to mirror the research objectives. This was piloted independently by three of the study team with the first seven participants, with feedback provided by the participants leading to revision of the topic guide (see Appendix 3). A total of 48 interviews were carried out face to face at a location chosen by the participants and 18 interviews were carried out over the telephone. All interviews were recorded with the consent of participants and transcribed verbatim.

Data analysis and reflections

Narrative analysis aimed to interpret how participants make sense of their experiences through story-telling, linking individual accounts to shared systems of meaning and cultures. Narratives were ‘read’ for their content (what they talk about) and form (how they talk it). An important reflection is that many participants appeared to see the interview exchange itself as a ‘political act’, and forms of attribution bias were clearly present in the narratives. Importantly, the narrative approach is less concerned with determining the ‘facts’ of a given situation and more with the perceptions and meanings of participants. For Josselson,82 this requires a degree of suspicion on the part of the researcher to interpret meanings or assumptions that might be disguised or layered under more explicit statements.

In practical terms, data analysis followed a ‘step-wise’ approach to interpretative data analysis. 86–88 This involved (1) familiarisation with data through close reading, (2) generating initial codes through the systematic tagging of data, (3) constant comparison of codes to assure internal coherence, (4) axial coding to identify second-order codes and to elaborate overarching themes, and (5) reviewing themes in the light of the wider literature.

Data analysis started with all members of the study team closely reading at least two transcripts to identify ‘interesting’ narratives of political skill to guide subsequent coding. Three members of the team (JW, BR and SB) then coded the data through close reading and open coding of transcripts. Codes were subject to regular review to clarify interpretation and internal consistency. ‘Second-order’ codes were developed incrementally through the categorisation and grouping of codes. These were then further aggregated in the form of overarching themes. In these later stages, themes were simultaneously related back to the research literature to confirm or challenge existing research and theory. Overall, in excess of 100 detailed stories were identified that described experiences of organisational politics and examples of political skill.

Methodological considerations

Work package 3 involved a qualitative case study approach. Case study research aims to produce a detailed description and analysis of a given ‘case’, which in many studies is representative of a broader phenomenon, but in others can be a rare, extreme or deviant case. 89,90 For health services research, case studies are especially relevant when seeking to understand how policy interventions are implemented in real-world settings. 91 Case study research is especially suited to the study of organisational politics because it provides fine-grained contextual understanding of how people interact and influence each other over time. 92

The initial study design proposed taking an ethnographic case study approach, with the aim of producing an immersive interpretative account of change processes. 93–95 It was recognised early within the study, however, that it would be challenging to carry out sustained in-depth fieldwork across multiple subcase study sites (i.e. the anticipated nine change projects). Specifically, the ability of two field researchers, even with the support of the wider study team, to carry out immersive longitudinal field observations tracking the ongoing development of nine different cases became unfeasible, even when field work was staggered across different time periods. The scheduling of field work was further complicated and compressed by the challenges and delays of case recruitment. For this reason, research was informed by the methodological principles of ethnography, especially developing an in-depth and interpretative understanding, but with greater reliance on time-limited observations of key events and greater use of interview and documentary data. 96

Sustainability and Transformation Partnership selection and recruitment

The study was designed to investigate change within three regional STPs as prominent examples of major system change. Given that STPs are made up of diverse portfolios of system change, the study intended to focus on three ‘subcases’ or system change ‘projects’ within each selected STP.

A preliminary desk review of all 44 STPs (completed during proposal development) identified key STP characteristics in leadership arrangements, strategic priorities and thematic areas for system change, such as urgent care, integrated care and mental health. Based on this desk review, three ‘candidate’ STPs were purposively selected during the initial application stage from Greater London and the Midlands to investigate differences in (1) geographical location and profile (demographic make-up, number of cities/towns and urban/rural features); (2) the number of large and specialist service providers; and (3) the profile of service transformation projects (with the intention of exploring both similar and different initiatives across the regions). Although these three sites were initially supportive of participating in the research, two of these later withdrew support and the research experienced significant challenges in recruitment, leading to both delays and variation in sampling and selection, the reasons for which are indicative of the organisational politics of health and care systems.

First, it was often difficult to determine where approvals should be sought within the STP governance structures and which body had statutory responsibility to approve research participation. Even when senior STP leaders were supportive of the research, managers from constituent NHS organisations could be less supportive, or vice versa. Although project teams or middle-level STP leaders were often supportive of the research, it took as long as 6 months to work through the various governance layers to find the group to authorise the research. Second, two of the candidate STPs experienced unanticipated changes in senior leadership, making it difficult to secure access. With one STP, the research team had many meetings with senior leaders over a 6-month period and eventually gained approval from the executive group; however, three members of this group then left their posts and the newly appointed leaders withdrew support for the study on the grounds that the recent leadership changes were ‘too sensitive’. Third, although STP leaders were highly interested in the study focus, they were often apprehensive about bringing to light ‘sensitive’ political issues during ‘live’ transformation processes. These recruitment challenges speak directly to the organisational politics of the STP agenda.

Given these challenges, STP recruitment was protracted and challenging. Following the planned approach, three candidate sites were approached through existing research networks, for example the National Institute for Health and Care Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs).

After 6 months of discussions with STP leaders, two of these candidate sites withdrew support: one because of the aforementioned leadership changes and the other because of perceived political sensitivities. After nearly 6 months of discussions, one site in the Midlands agreed to participate. Another candidate site in Greater London was approached and, following another 6 months of negotiations, approval was granted. In parallel, all STPs in the Midland regions were contacted in writing to invite them to participate. Following a further 6 months of discussions, one STP agreed to participate. Because of the challenges around recruitment of STPs, case study data collection was delayed by over 6 months in two sites and by over 1 year in the other. The recruited STPs’ case study sites are summarised in Table 3, and the STP regions have been given pseudonyms to protect the anonymity of participating sites. Shortly after commencing fieldwork with this third site, field research was paused because of the COVID-19 pandemic (the impact of this is discussed in The impact of the COVID-19 pandemic).

Subcase transformation project: selection

The study design proposed to select three ‘subcases’ of system change within each selected STP. This was based on the assumption that the politics of system change would vary between the more ‘strategic arenas’ of high-level STP leadership and the more ‘operational arenas’ of system change. Informed by the preliminary desk review, common system transformation domains were identified, including urgent care, health and social care integration, and resource prioritisation. However, during STP recruitment, senior leaders asked the research team to focus on transformation projects that they regarded as priority issues, which were accepted as subcases on the basis of being a necessary compromise to support research access. Nevertheless, the selection of subcases took into account the difference in the focus of transformation, especially whether they were focused on the strategic or the operational levels of change, and how each project contributed to the overarching STP priorities. As described below, each subcase offered a distinct analytical focus for the study.

The recruited STPs’ subcase study areas are summarised in Table 4. Study names have been modified to protect the anonymity of teams.

Selection and recruitment of individual participants

The recruitment of individual participants was also purposive, based primarily on a person’s direct or indirect involvement in system change and with the intention of exploring variations within and across project activities. 85 Participants were identified and recruited through three techniques. First, a review was undertaken of publicly available STP documentation that identified people involved in STP governance and project management, that is from organograms. Second, people were identified as potential participants during observational research, that is based on involvement in project work. Third, participants recommended speaking with others to pursue particular lines of enquiry as a form of ‘snowball’ sampling. All participants were provided with the study participant information sheet and gave written consent.

The study protocol anticipated recruiting representatives of patient groups involved in and affected by the proposed service transformations. A surprising finding was the limited involvement of patient or public groups in ‘day-to-day’ project activities. Most projects involved some formal public or patient representative from a recognised charity or advocacy group, and most of these people participated in the study. However, there was little wider service user or public engagement, which then limited the scope to involve such people in the research.

The impact of the COVID-19 pandemic

It is important to acknowledge the impact of the COVID-19 pandemic on fieldwork. By the end of February 2020, data collection at the Greater London STP (Blue) was nearing completion and data collection at one Midlands STP (Green) was progressing well, with two subcase studies completed and the third under way. The second Midlands STP (Red) had agreed to participate and data collection was under way with senior system leaders and introductory meetings had been held with project teams. Following the introduction of the first UK ‘lockdown’ in March 2020, and in accordance with NIHR guidance, data collection for WP3 was paused, with activity focused on completing data analysis and preparing WP4.

At this time, it was decided to conclude data collection with the Greater London site. The Midlands STPs were contacted to discuss the ‘pause’ and to agree ways to restart the research in due course. One month into the pause, the research team was contacted by the lead of the project team for personal health budgets (STP Green) with the news that this project had been terminated. They reported that, owing to the pandemic, funding for the initiative was no longer available and members of the project team had returned to their primary ‘jobs’ to respond to COVID-19. Sufficient data had been collected up this point to provide important learning about the challenges of project set-up, from which a case report was developed. This concluded data collection at the first Midlands STP (Green).

Following the end of the first lockdown, the second Midlands STP (Red) was contacted to discuss recommencing the study. At this time, it was communicated that data collection could not recommence until the autumn owing to a backlog of work and new challenges associated with the pandemic. Further contact was made with the STP in early September to discuss data collection. At this time, the ‘cancer care’ project team indicated that they could no longer take part in the study owing to excessive work demands. Data collection with the ‘transforming the patient journey’ and ‘workforce development’ project teams was rescheduled for October to December. By the time that data collection was about to recommence, there was an increase in COVID-19 cases and hospital admissions and, subsequently, in November, a second lockdown. At this point, the ‘patient journey’ project team withdrew from the study owing to unprecedented work demand. The overarching STP leadership agreed to continue involvement in the research with the ‘workforce development’ and ‘system architecture’ project teams. However, as a result of the second lockdown and additional pressures on the service, data collection was further delayed and relied primarily on remote interviews carried out between December 2020 and February 2021. One of the advantages of in-depth qualitative work is that it enables collection of a large number of data in various forms and, therefore, when data collection was possible, there is sufficient data to meet the study objectives.

Data collection

The in-depth case study research involved a combination of qualitative methods, including semistructured interviews and group interviews, focused observations and shadowing, ‘in site’ ethnographic interviews and documentary analysis.

Data analysis

Data analysis involved three complementary approaches that moved from ‘within’-case to ‘cross’-case analysis, and then re-engaging with the analysis that was undertaken in preceding WPs.

First, data from each case study STP and transformation project were analysed with the intention of producing individual case reports. As with earlier WPs, an empirically grounded and interpretative approach was followed. 86–88,95 Specifically, case study data were open coded and summarised by Justin Waring and Bridget Roe by identifying common and distinct features: project/service focus, project maturity, project team members and stakeholders, significant issues or controversies, observed or reported actions and interactions, and project outcomes.

Second, a ‘rich’ descriptive account was produced for each STP and subcase. Following Stake,89 case reports were organised to give (1) an entry ‘vignette’ to set the scene and provide relevant background information, (2) a narrative account of the case that described the people involved and issues addressed, (3) a detailed account of the key or defining issues of the case, and (4) assertions or interpretations of the account relevant to the study objectives. In preparing these case reports, the thematic analysis from the preceding interview study was used to inform analysis in terms of the ‘controversies’, ‘protagonists’ and, in particular, the types and forms of ‘skills, behaviours and practice’. Data analysis showed that each transformation project experienced a range of political controversies, but that each was defined by a small number of key controversies at different stages of the change process.

The third stage involved cross-case analysis with the aim of identifying and explaining common and unique features,85,90 specifically how certain types and patterns of political skill were used around particular controversies. Preliminary cross-case analysis involved comparative ‘process mapping’ to understand how each case evolved over time, comparing ‘where’, ‘when’ and ‘why’ events occurred, ‘who’ was involved and ‘what’ they did. 90 From this, a ‘composite’ synthesis was developed of the ‘system change processes’, building on the existing literature on major system change. 2 Each case report was then reanalysed to illustrate a significant controversy within this composite picture of system change (see Chapter 5, Figure 9). For instance, some case reports illustrate the political issues experienced earlier in project planning or prioritisation, whereas others illustrate issues experienced later in project implementation or closure.

Activity 1: a review of the literature on the acquisition and development of political skill

Activity 1 was undertaken as part of WP1 and involved a review of the literature to identify and summarise research on the acquisition and development of political skill. The selected review papers were further analysed to identify and categorise the methods and approaches for supporting the acquisition and development of political skill. In addition, a manual search was undertaken of prominent textbooks and monographs on political skill and leadership development (that would have been missed in the earlier search). This resulted in a total of 24 research papers and five monographs. The review summarised the main methods of acquiring and developing political skill, the pedagogic features of these methods, and the reported positive and negative features in terms of delivery, experience and learning.

Activity 2: qualitative interviews with service leaders

Activity 2 was undertaken as part of WP2 and involved carrying out narrative interviews with health and care leaders to understand their experiences of acquiring and developing political skill over their careers. As reported above, 66 participants took part in these interviews, including 16 people who were undertaking or had recently undertaken formal leadership education or training. All participants were invited to reflect on significant learning events and situations, including formal training and more everyday encounters. Participants were also invited to offer recommendations for how future leaders might learn and develop these skills.

Activity 3: a pragmatic review of training and development literature

Activity 3 involved a pragmatic review of frameworks, tools and learning resources that are specifically designed to support the acquisition and development of political skill or related capabilities. This review involved a pragmatic search of well-established leadership development agencies, university courses, professional press and other leadership development frameworks.

The pragmatic review started by carrying out interviews with four experts in leadership development to discuss the emerging study findings and to understand how current leadership programmes address the theme of political skill. Informed by these interviews, an online search was carried out of health and care leadership development agencies, including the NHS Leadership Academy (Leeds, UK), The King’s Fund (London, UK), The Health Foundation (London, UK) and the Institute for Health Improvement (Boston, MA, USA), and the online archives of agencies, such as the NHS Institute for Innovation and Improvement (Coventry, UK). An additional online search was undertaken of commercial and non-commercial leadership development frameworks, including sources in the field of international development.

The identified frameworks, tools and resources were reviewed and categorised by Bridget Roe and Justin Waring, summarising (1) the express purpose of each tool or resource, (2) the originating source or underpinning theory, (3) key constructs about pedagogy or change, (4) the method of delivery and (5) the evidence base. Practical considerations were also recorded, such as the time needed for delivery, acceptability and actual or potential adaptation. A shortlist of candidate approaches and tools was created based on (1) the clarity and relevance of pedagogy, that is do they have a developed understanding or theory of learning; (2) alignment with the study’s empirical themes; and (3) feedback and recommendations from the preliminary workshops. The candidate list was then further reviewed and deliberated with study advisors in the light of the study findings.

Activity 4: workshops

Activity 4 involved facilitating a series of workshops to iteratively develop learning resources and materials. The workshops were initially planned to take place after the completion of data collection; however, following discussion with the study’s scientific committee, the workshops were configured to take place alongside the early WPs to inform the extrapolation of learning.

An initial set of three workshops was carried out in conjunction with WP1 to explore the perceived learning needs for health-care leaders to acquire and develop political skill and to consider how existing leadership programmes address these needs. An ‘educator workshop’ took place that involved seven people recruited through university networks, including representatives from Health Education England and the NHS Leadership Academy, three university-based providers of leadership education and two workforce development leaders from different NHS trusts. This workshop focused on the contribution of existing leadership development frameworks to service leaders’ acquisition of political skill. A ‘practitioner’ workshop was carried out with 12 health service leaders working in the area of quality improvement, who were recruited through a regional quality improvement network. This workshop explored participants’ understanding of organisational politics and recommendations about how political skills could be addressed in leadership development programmes. An ‘expert advisor’ workshop was carried out with four research experts (including organisational studies, public policy and management, and leadership research) and four relatively senior NHS executives to develop a greater understanding of the conceptual aspects of organisational politics and political skill. All three workshops were recorded and transcribed verbatim.

A fourth workshop was carried out in conjunction with WP2 to clarify the emerging analysis from the interview study. This workshop was organised as a dedicated session of a national Q Community knowledge exchange event. The Q Community is a network of people who are actively engaged in improving the quality of care services. It is supported by The Health Foundation, in conjunction with NHS England, and hosts various developmental events. The study team were invited to facilitate a workshop on ‘Harnessing Political Astuteness’ at a Q Community event on 13 November 2019. Nearly 60 delegates participated in the workshop, which explored their views about organisational politics, the impact on service improvement and how people can learn to use political skills in improvement work. These views were recorded through the use of flip charts, Post-It^® notes (3M, Saint Paul, MN, USA) and other verbal summaries.

A fifth workshop was organised to review and appraise the shortlist of ‘candidate’ tools and resources that had been identified through the pragmatic scoping review of leadership development frameworks. Workshop participants included five specialists in knowledge exchange, capacity development and implementation science, who were recruited through the NIHR CLAHRC infrastructure. Participants were asked to review the identified tools and to consider their relevance and application to health-care services. Through this workshop, the candidate list of learning tools and resources was appraised, with recommendations offered on how the tools and resources could be adapted for use with health and care leaders. In addition, the workshop discussed the design, content and use of a complementary ‘workbook’.

A final series of four co-design workshops was carried out after the completion of primary data collection, which aimed to iteratively develop, pilot and appraise candidate learning resources and materials. Co-design has a relatively long history97 and has had a significant influence in health policy-making, research and service improvement. 98 In broad terms, this rests on the idea that the users and beneficiaries of a given service, product or research activity should be involved in its design, specification and application for it to be more meaningful, relevant and legitimate to these communities. 99 The four workshops were carried out with different learner communities or groups to understand whether they were better suited to different audiences or change agendas. Two workshops were organised with STP project teams (recruited following participation in WP3). One workshop was carried out with a regional Healthwatch organisation on the basis that the organisation explicitly aims to promote community and patient perspectives in decision-making. Furthermore, although being a recognised part of the health and care system, these organisations are unlike statutory care providers and, therefore, offer a distinct opportunity for testing the learning materials. In addition, one workshop was organised as an ‘open’ public invite for any person involved in managing or leading health service change, but without the expectation that participants would be working on the same change agenda; this, therefore, offered insight into whether or not the learning materials can be used by a heterogenous group. All workshops lasted 3 hours and were facilitated by study team members via Zoom (Zoom Video Communications, San Jose, CA, USA) because of the COVID-19 pandemic restrictions. Each workshop involved between 7 and 15 participants.

A structured co-design approach100 was used for the workshops, with clearly defined organisational groups working on discrete change projects, but not for the ‘open’ workshop. First, the project leads and other team members were invited to a pre-workshop planning meeting to discuss their learning needs, clarify their change project, share their preferences for the organisation of the workshop and identify any potential ‘sensitivities’ that should be considered. Second, the learning resources and activities were revised in accordance with the bespoke requests and feedback from project teams. Third, the learning tools and resources were delivered through the workshop. Fourth, immediately after the completion of the workshop, participants were invited to give feedback on the meaningfulness, relevance and application of the learning resources and tools to their change project. Finally, 2–3 weeks after the workshop, the project lead and other participants were invited to give further reflective feedback on the relevance and use of the materials for their ongoing activities. The ‘open-invite’ workshop did not involve the pre- and post-workshop activities because participants were not working on a shared project, but participants were invited to give immediate feedback.

Activity 5: recruitment workshop/interviews

The final activity involved carrying our four semistructured interviews with people working in NHS human resources (HR) management and talent management. The interviews explored how current recruitment practices assess the political skills of applicants for employment or promotion. This included further appraisal of the study findings and candidate learning resources, with recommendations for how the tools and resources could be adapted for use by HR managers, that is as selection tools or situation-based activities to assess candidate understanding of organisational politics. This led to the development of a question topic guide for use during recruitment interviews.

Review findings

Mechanism and outcomes

All reviews tend to describe political skill as making positive, sometimes necessary, contributions to the implementation of strategic change. Much of the literature applies the Ferris et al. 53 constructs to predict and explain variability in individual, group or organisational performance. A preliminary observation is that all reviews describe (or assume) ‘political skill’ as being an attribute or quality of an individual, which is used or enacted through their interactions with others. Although this body of research recognises that interpersonal influence is often manifest through group dynamics, the primary analytical focus is on the individual and their capacity or skill to enact this influence, rather than the wider group dynamics. For this reason, the mechanisms of change are grounded ‘in’ the individual and realised ‘through’ their interpersonal relationships with others. However, few reviews explain the interaction between these causal properties or attributes, for example how ‘interpersonal influence’ relates to ‘networking ability’. In seeking to clarify or develop a heuristic model, it could be suggested the Ferris et al. 53 concept offers a more linear view of the dimensions of political skill (Figure 2), which can be summarised through the following propositional logic:

1. Heuristic proposition of political skill53 – to enhance one’s personal or organisational objectives through influence with others requires (1) social awareness to understand opportunities for change and to develop a realistic plan, in which actors can use (2) networking abilities to access resources and information in support of this plan, alongside their use of (3) interpersonal influence to realise the implementation of their plan, while at same time presenting their (4) apparent sincerity to ensure that people do not feel that they are being manipulated.

FIGURE 2.

Heuristic interpretation of Ferris et al. ’s53 conceptualisation of political skill.

The Hartley et al. 52,113 concept of political astuteness offers a different propositional logic and a more dynamic view of how the dimensions of political astuteness interact and contribute to how a person seeks to understand and align interests (Figure 3):

1. Heuristic proposition of political astuteness – to achieve the desired outcomes through aligning diverse interests and securing consent requires (1) strategic direction and scanning to understand and articulate the organisation’s strategic goal, and in parallel (2) the ability to read people and situations to understand the barriers to and drivers of change, which then informs (3) the use of interpersonal influence and (4) the ability to build alliances to realise strategic goals, while drawing on (5) personal skill to manage the perception of others.

FIGURE 3.

Heuristic interpretation of Hartley et al. ’s52 concept of political astuteness.

A number of reviews describe aggregated statistical associations and correlations between measures of political skill (as an independent variable) and different individual, interpersonal or organisational outcomes (as dependent variables). For example, individuals ‘high’ in political skill experience the following effects/outcomes:

• high levels of team cohesion and team success120

• trust and confidence in others120

• interactions with enthusiasm and confidence110

• positive and high levels of job performance/success (but not salary)43

• high levels of job satisfaction110

• low levels of workplace stress43

• effectiveness in informal interactions43,104

• affects teams through evaluating and planning activities, uses effective communication, manages conflict and facilitates group cohesion111

• enhances both leaders and followers, leading to better outcomes. 112

At the individual level, the reviews suggest that those with high degrees of political skill tend to have higher levels of self-efficacy, job satisfaction and career success and lower levels of stress. 57,102,107,114,120 The reviews also show that political skill is self-perpetuating, so that those individuals successful in using their political skill become more successful and continue to use these skills. At the interpersonal level, the reviews show that those with high degrees of political skill are more capable of influencing and persuading others. 43,109,110,113 This influence is manifest, for example, through the ability to create and articulate a vision, motivate others, build trusting relationships, win the confidence of others, foster positive and high-quality relationships, mobilise rewards and incentives, negotiate differences and manage conflict. 102,110,113 Interpersonal influence produces advantage for the individual with political skill, and is shown to contribute to both group and organisational performance. At the group or team level, the review papers show that those with high degrees of political skill tend to be able to foster team cohesion and strong interpersonal relationships, especially through articulating shared goals, managing interpersonal conflict and supporting team development. 102,106,110,113

A relatively small number of reviews make reference to the contexts within which political skill is situated. 102,113 The majority of studies appear to draw on data from the private sector, or they do not state the specific context, but these rarely elaborate the particular contextual features or how these vary between sector or business. The exception to this is the literature on ‘political astuteness’ that looks at civil servants,54,113 and also Montalvo,102 who explores the health-care setting through the political skill of nurses. In summary, the literature tends to describe political skill or associated terms as a highly individualised set of traits and qualities that are enacted through interpersonal influence to affect change around individuals, groups and organisations.

Discussion

The ‘review of reviews’ found that political skill, as defined by Ferris et al. ,53 is the predominant concept for describing how individuals influence others and implement change in the context of organisational politics. The Ferris et al. 53 concept comprises four well-developed and empirically validated constructs (social astuteness, interpersonal influence, networking ability and apparent sincerity) that provide the basis for a large body of research, and is positively associated with different individual, interpersonal, group and organisational outcomes. The literature tends to present political skill, as informed by Ferris et al. ,53 as highly individualised skills, attributes or traits that are manifested through interpersonal relationships. 53 In contrast, research on political astuteness offers an alternative conceptualisation, especially for addressing the interplay between the individual and their context, moving beyond internalised skills to think more about the relational behaviours and forms of influence. 113 Furthermore, the vast majority of primary sources described in the reviews were quantitative in design,107,110,121 involving statistical analysis of an individual’s degree of political skill in relation to team and organisational performance. 111 Some reviews do refer to qualitative interview studies, but few offer detailed ethnographic studies, with the exception being the textbook by Buchanan and Badham. 41

Through this ‘review of reviews’, we identified a number of conceptual features from which there is potential to develop additional and complementary lines of analysis. First, it is important to disentangle the idea of skills and capabilities (as a form of ‘potential’ residing within individuals) from behaviours and actions (as enacted skill in a relational or social context). The existing literature seems to conflate these two aspects so that political skill is seen as both the underlying capability for influence and, simultaneously, the behaviour of influence. Moreover, skill or capability is largely described as residing within the individual, whereas the behaviours and actions are typically manifest through interaction in the given context. Arguably, these represent subtly different aspects of the broader phenomena of engaging in organisational politics.

Second, it is important to develop a more interactional and contextual understanding of political skill and behaviour as being manifest through interpersonal relationships. Much of the existing literature seems to present a unilateral view that ‘Person A’ (with political skill) exerts influence over ‘Person B’ (without reference to their political skill). However, it is important to recognise that all actors will have some form and degree of political skill and all will be influencing one another throughout their interactions, whether intentional or not. This suggests a more dynamic and interdependent notion of political skill and interaction, in which the moves and counter moves of different actors shape the political environment. More significantly, however, it could be argued that the unit of analysis could be extended beyond the individuals and their skills to the relationship between individuals and groups.

Third, and stemming from the above, the enactment of political skill and behaviour is inherently situated and context specific; this is something that the identified reviews appeared to overlook. For this reason, in one encounter a person may appear to have high degrees of political skill and behavioural influence over others, but in other situations the same person may appear to have relatively limited forms of skill and influence, either because the situation presents different challenges or because the people in this particular situation have greater levels of skill than those in the previous situation. In other words, a person’s political skill is relative to the relational and situational context. Taking this line further, it suggests, therefore, that when analysing political skills and behaviours, perhaps more attention is needed to the context and relational dynamics than to the individual.

Review findings

Thematic analysis

Discussion

The review found that over the last four decades concepts such as political astuteness, skill and savvy have been most applied and developed within the nursing field, including notable conceptual articles that predate much of the organisational studies literature116 and review articles that summarise nurses’ use of political skill to influence policy-making and organisational change. 102,139 Looking beyond nursing, the concept of political skill is used to describe how hospital managers, other health professionals and, more recently, system leaders seek to introduce organisational or interorganisational change. 134 What unites many, but not all, of these studies is the idea that leaders need to develop and deploy political skill because of the perceived dominance of other health-care professionals, who are often presented as resistant to change. Sometimes, political skill appears to be a strategy to counter the informal ‘power’ of the medical profession.

The review also showed how the conceptualisation of political skill and associated terms within the health services research literature vary considerably and that there is limited definitional or conceptual agreement. Much of the earlier research, especially in nursing, uses terms such as ‘political astuteness’ and ‘political skill’ in a largely descriptive and generalised way with limited theoretical underpinning. 116 Subsequent research has been enhanced by concepts drawn from management studies, but it is only with the later use of Ferris et al. ’s53 concept that a clear and distinct concept of political skill has informed research. 102,131,139 For this reason, there is a noticeable shift from a relatively ‘loose’ descriptive concept to a ‘tight’ analytical concept. Although this shift results in enhanced descriptive and analytical clarity, it risks marginalising certain aspects in favour of others. The five aspects of political skill presented in this review (personal performance, contextual awareness, interpersonal influence, stakeholder engagement and network building, and policy influence) are directly comparable to the work of Ferris et al. ,53 but they also highlight factors beyond individual skills in ways that more explicitly address the wider organisational context of health-care services. 53

The review also found that the research evidence underpinning these different conceptualisations varies considerably. There is more descriptive evidence on the importance of leaders’ ‘contextual awareness’, ‘stakeholder engagement’ and effective ‘communication’. However, the evidence base appears relatively underdeveloped for ‘interpersonal influence’, especially as there is little empirical or analytical detail about the form of this influence beyond relatively general accounts of negotiation, persuasion and coercion.

As with the wider social science literature, the health services research literature rarely explores the interconnections between the different aspects of political skill. For instance, individuals’ use of ‘stakeholder engagement’ appears to be collapsed alongside building ‘networks and alliances’; however, these might better be thought of as two related, but distinct, processes that require different skills. Even those studies that drew explicitly on the framework of Ferris et al. 53 tended to treat the different dimensions of political skill as relatively discrete variables, with only a small number of papers elaborating the interconnections between the constituent parts of political skill. One example is Montalvo’s102 integrative review that shows political skill as operating first through ‘the self’, then through influence on ‘others’ and then on the performance of the ‘organisation’.

This review provides a foundation for exploring the connections, relationships and dependences between these themes in the form of a more integrative conceptual heuristic (Figure 4). Specifically, the literature suggests a close connection or interplay between ‘personal performance’ and ‘contextual awareness’, in that leaders need to effectively understand their own skills and capabilities relative to existing lines of power. This provides the orientation and basis for ‘interpersonal influence’, in terms of understanding who to influence and how to influence them. In turn, such influence extends from the individual to the group level through ‘stakeholder engagement’ and, in parallel, ‘network building’, which provides the basis for co-ordinated and collective ‘organisational change’, often in the context of opposition. Moreover, stakeholder engagement and networking can provide positive feedback loops for enhancing interpersonal influence with other stakeholders. Finally, and somewhat tangentially, the literature also suggests that leaders can also seek to use political skill to engage in more formal ‘policy influence’, perhaps to reinforce the more informal forms of political skill.

It is important to acknowledge the wider health services and social science literature that describes the micropolitics of health-care organisation and delivery, but which was not included in this review because it rarely deploys the concept of political skill, or an associated term. This includes, for example, a long tradition of research on the negotiated order of health-care organisation that focuses on the interactive dimension. 69,141–143 In addition, more critical and interpretative perspectives bring to the fore the influence of prevailing structural interests and ideological forces on the local manifestations of change, such as the divergent agendas around professionalism and managerialism. 16,56 Importantly, this literature demonstrates the importance of looking beyond individual skills and capabilities to understand the social and cultural context of ‘political action’, together with more explicit recognition of the structural inequalities that frame organisational politics related, for instance, to issues such as profession, gender, ethnicity or class. As such, a significant limitation of this review was the exclusion of many seminal and influential texts in the field of health-care policy and politics, such as Alford’s Healthcare Politics17 or Klein’s The New Politics of the NHS: From Creation to Reinvention. 144

FIGURE 4.

Conceptual heuristic of political skill derived from the narrative review.

Second, the relational dimension recognises the limits of taking an individualised approach and, by implication, directs attention to the collective dimensions of organisational politics and political action. Although individuals might have certain forms and degrees of political skill (following the dominant Ferris et al. 53 approach) from which to effect change, it might be suggested that in complex organisations and systems the range of political challenges and conflicts that have an impact on the implementation of change will require more than the skills and competencies of a given individual. That is, they are likely to need groups of people with complementary skills and abilities. Moreover, change processes occur over time and space, involving multiple interlinked stages. For this reason, it is more likely that multiple actors with complementary skills or abilities will be involved in implementing change, as suggested by research on social movements. 10,145 In other words, there is a need to move beyond the focus on the individual change agent or transformational leader to think about more distributed forms of political skill and action. 22

Third, a more relational and social view of organisational politics highlights the idea that political activities are structured or organised according to shared (and divergent) cultural meanings, norms and beliefs. These ideas represent an important departure from mainstream thinking on political skill, because they bring to the fore the idea that people engage in organisational politics from different positions of status and power. 63 Therefore, for example, some groups within an organisation may be relatively privileged by formal authority or professional background, which conditions both the need to act politically and what type of political actions they might take. Those that are less privileged by the established order might have a different need or inclination to act politically and might also need to use certain skills, or rather strategies, because of their particular access to resources, roles or relationships, which are a reflection of their social position. 26 As such, there is a need to look beyond the political skills of individuals, to understand the political actions and interactions of people who are embedded in broader fields of social relations and inequality.

Fourth, the mainstream approaches to political skill tend to suggest that people use their skills to influence others with the aim of obtaining their self-interested goals, often in terms of career enhancement, personal status enhancement or group performance. Within the health services research literature, there is greater appreciation of the way that political skill might stem from professional interests in the context of service change. 16 However, there is relatively limited appreciation that political skill or political action might be shaped by deeper, even subconscious, beliefs, interests and agendas. In the health and care sector there has been longstanding interest in the relative power of professional groups within the division of labour, in which attempts to promote or resist change have been interpreted as strategies to articulate deeper collective interests. 66 As noted above, such studies talk indirectly to the idea of political skill or practice, but nevertheless surface the underlying dynamics of power that shape care services. Extending this line of thinking, greater attention is needed to connections between individual or collective political action and the interests and agendas that inform or guide them.

Finally, the reviews show that almost all of the existing literature deals with political skill at the intraorganisational level. Within the wider social science literature, there is a tendency to focus on what might be termed ‘office politics’ between workers. The seminal work of Pfeffer38 and Mintzberg40 locates political skill in a context of broader strategic change and, further still, Hartley and Fletcher54 locate political astuteness in the context of political systems. However, there is a paucity of research dealing with political skill at the interorganisational or system level. This is highly relevant to contemporary health and care reforms that seek to reconfigure the organisation and delivery of care at the ‘system’ level. Furthermore, when change is planned or occurs outside formal organisational authority structures, as in the case of system change, social actors often need to draw on interpersonal influence or political skill to realise change in the absence of formal role authority. For this reason, system change offers an important site for developing new theoretical understanding of interorganisational politics and political practice.

Self and interpersonal style

The first theme describes the personal and interpersonal qualities that are commonly associated with political skill and action. These qualities were commonly described as the foundations for more strategic and tactical forms of action; for example, the ability to be (and be seen as) ‘assertive’ or ‘authentic’ was linked to other forms of action, such as ‘building relationships’. For many, these personal qualities were based on the principles of ‘reflective practice’ or, in broader terms, self-awareness or the capacity to realistically appraise one’s own abilities relative to others and in a given situational context:

So it’s about me knowing who I am, and I suppose if I know who I am, I am more likely to understand other people, and have empathy for other people, so maybe emotional intelligence, linked in with leadership, but I think that they overlap because of that motivation, that drive and determination, that self-awareness, that being open to feedback, because if you’re comfortable with yourself, and knowing your own strengths and weaknesses, then actually that’s fine, and appreciating that we’ve all got that but then within a team, trying to play to everybody’s strengths.

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Many participants described the importance of ‘self-belief’. This was described in three ways: first, with participants’ belief in their personal motives or intent for acting politically, that is ‘doing the right thing’; second, with participants having confidence in their own abilities, that is they have the ‘right skills’; and third, with participants believing that they will succeed despite resistance, that is ‘being resilient’. Alignment between these different aspects would create the conditions for engaging in politics, whereas a misalignment could, for some, discourage political action: I want to do the right thing but I do not have the skills to deal with a given issue.

Participants described organisational change as a drawn-out process, in which leaders often needed to ‘play the long game’, ‘stay the course’ or wait for the ‘windows of opportunity’. In some cases, change was depicted as a ‘war of attrition’, in which personal and emotional losses had to be weathered. Accordingly, being resilient and having perseverance were seen as essential personal qualities for engaging in organisational politics.

Participants described a discrete set of personal qualities related to understanding and managing their emotions, what might also be labelled as ‘emotional intelligence’. 146 First, it was described as important to effectively appraise the emotional mood surrounding a given change agenda, which relates closely to the ability to read the political landscape (see Strategic awareness and thinking). This suggests that change (and the response to change) not only is a matter of rationality or evidence-based decision-making, but also involves understanding people’s deeply held beliefs, values and emotions. For this reason, change often involves anticipating for emotional responses to change:

So, it’s being aware of your own personality, again, which comes back to emotional intelligence, it comes back to your political influence small ‘p’ because of your interpersonal influence, and the skills that you have, in your toolkit, to be able to influence someone.

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Second, participants talked about managing the presentation of their own emotions. The ability to appear empathetic with those struggling with change, for example, was seen to be important for maintaining positive relationships and minimising resistance. In other ways, limiting one’s emotional responses could project a more professional demeanour to show that a person was above or not influenced by emotional considerations. In this sense, the self-regulation of emotion was described as a strategy for managing the responses of stakeholders that was based on the ability to listen to and understand the emotions of others.

Although self-awareness and self-belief are primarily concerned with how participants think about themselves, such talk demonstrates the importance of understanding how to present one’s self with others when seeking to influence these others. In various ways, participants described displaying appropriate forms of physical, interpersonal and emotional behaviour that reflected their self-belief and commitment to change while being responsive to the expectations of others. For this reason, effective leaders were sometimes described as ‘chameleon-like’, in that they could change their presentation to align with the expectations of audiences. Accordingly, those with relatively fixed or entrenched demeanours were often seen as inflexible:

So you look at it, you then just sort of adapt your style and it’s, and is it your body language, because then you’re thinking, OK I was getting quite comfortable here, just listening, but actually I’m in the work mode and this person has only got half an hour and I’ve only got that amount of time, to influence them, for the first time, but as I say, it’s about being able to continue and to develop that relationship.

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The ability to manage presentational style could involve, for example, using the ‘right’ language or dressing in an ‘appropriate’ way. As an illustration, one participant talked about not being seen as ‘too managerial’ when engaging with clinical groups, whereas others ‘talked up’ their clinical background to enhance their standing with front-line clinicians. However, there seemed to be a balancing act with how much one could alter one’s representational style because of the risk of being seen as inauthentic.

Looking closer at these representational styles, the majority of participants talked about the importance of having, or being seen as having, ‘integrity’. In slightly different ways, this involved being honest and faithful to one’s own beliefs and values, as well as the shared values of the health and care service (which were somewhat more variable). In other ways, people talked of being transparent and not seeking to deceive others. Participants offered cautionary accounts of co-workers whom they regarded as manipulative, inauthentic or lacking integrity.

Some participants elaborated this as having an ‘authentic’ style. This was described as being honest to one’s self and being ‘genuine’ in relationships with others, or not cultivating a presentational style for the purposes of influence. Caution is needed in interpreting this idea of authenticity because there remains a possibility of creating an authentic style with the intention of influencing others, which could be inauthentic:

. . . got to be yourself haven’t you, and celebrate yourself. And that’s where the sensitivity . . . and understand how other people might experience you. And for good and bad, and I think just understand that and own it.

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In other ways, and not always consistent with the idea of integrity, participants talked about being ‘charismatic’. There were many accounts of leaders using their personal charisma to inspire others. This seemed especially prominent among medical groups in which charismatic leadership tropes were aligned with mastery of shared symbolic markers around clinical reputation:

It’s that charisma bit around actually they generally look like they’re quite interesting people and they’ve got a certain presence around them, I think they tend to be more yeah skilful, political operators in that respect in that they can get on with a lot of people and they can get a lot of people to work around a similar cause.

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Another example of interpersonal style was associated with being ‘diplomatic’ or being attentive to, and considerate of, the diverse interests of different stakeholders. Although this diplomacy relates to a vast range of political skills and strategies that are described below, the key point here is the ability to cultivate and project a diplomatic style:

What he did, he navigated some very bumpy political waters and I think kind of, I’m sure had to bite his tongue for a lot of things. Because I guess effectively he had a number of brownie points and he knew he needed to play them when he needed to play them, would be my thought.

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By contrast, participants talked about a more ‘assertive’ or directive interpersonal style that involved, for example, standing up to dominant or powerful groups and challenging inappropriate behaviours. What seemed important, however, was knowing when to be more assertive through assessing the context and anticipating the response of others:

It’s really important to be articulate, be assertive and I think what comes with experience, and I didn’t have this when I started off as a nurse director, is just taking time to really understand others’ perspectives because I think I was probably a bit bombastic and I knew what was right because I was the nurse director and I knew what patients needed, so I think that I needed to just moderate my approach a bit.

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Strategic awareness and thinking

The second theme describes how participation in organisational politics requires forms of ‘strategic awareness and thinking’ for understanding the local political context, formulating realistic goals and plans for change, and selecting the corresponding ‘tactics’ for realising these plans. As with the other themes, the aspects associated with strategic thinking do not fall into neat categories, but rather illustrate clusters of qualities that are linked to other aspects of political action.

Many participants described the need to ‘see the big picture’ or to understand the wider economic, organisational and political context of health service change. This included the broader (big ‘P’) political landscape of national policy priorities, regulatory requirements and wider resource issues that set the context for the local organisational politics. For a small minority of participants, direct exposure to, and involvement in, formal political settings afforded developed understanding of the skills used by politicians in engaging with different stakeholders:

Working at a national level, working for a regulator, there are massive politics, with a big ‘P’ and a small ‘p’ because you’re so close to Westminster that actually your chief exec[utive] is meeting with the Secretary of State every Monday morning, that feels very real when you work in an arm’s length body and then of course because there are several arm’s length bodies working in the national health and care system there are big politics between them all, so I, so the experience of working with, in that environment was fascinating because you’re getting, well you’re getting very interesting dynamics between very senior people.

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Participants talked about ‘understanding the history’ of health service reform, especially the changing political ideas that have shaped policies and the historical conditions that enable or constrain certain types of change. 9 Some participants talked of ‘learning from the past’ to avoid common pitfalls, such as the engrained challenges to integrating health care and social care or the challenges of regulating medical practice. In common ways, these views suggest that those leading change need to trace both the historical roots and the development of the given intervention and, at the same time, appreciate the history of similar events within the local context that might condition how a given change is received:

Be able to look at the wider picture . . . I did that when I was doing that job to go really wide and bring it down. . . . so I think you need to have an appreciation of the macro picture.

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A connected form of strategic awareness is understanding the local political landscape that surrounds a given change agenda. Most participants talked, for example, about recognising the prevailing ‘lines of power’ within care services, from the formal governance structures to the informal lines of power that shape day-to-day care delivery. The formal governance systems of the NHS were widely described as exhibiting high degrees of complexity and incoherence that could drive change in some areas but inhibit change in others. Understanding the governance landscape and appreciating what financial, clinical or regulatory ‘buttons’ to press were seen as essential skills for navigating formal authority structures.

Some participants talked, for example, of navigating the formal ‘chain of command’ when seeking to gain authorisation and funding for proposed change initiatives:

So many departments, teams, organisations and the conflicts between them, in terms of understanding what the whole system needs but knowing what the regulatory landscape requires of them, within their particular silo, or within their particular department, or unit, or whatever it was.

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Almost all participants described how formal governance arrangements were complicated by informal lines of power and influence that, in some ways, appeared to shape the day-to-day organisation of care more than formal requirements. Participants talked, for example, of understanding how ‘influential individuals’ and ‘dominant cliques’ regularly complicated change processes. Doctors were commonly seen to resist change that challenged established ways of working or undermined professional status; however, other occupational groups were also highlighted as acting politically to either block or promote certain types of change, especially nurses, managers and patient advocacy groups. Participants’ narratives often foregrounded a significant ‘other’ as acting politically to complicate change or maintain established ways of working to safeguard some position or interests that they held. However, the narratives also suggested that informal influence was not always aligned with a specific professional group, but could vary according to the issue at hand. That is, some issues saw professional groups working together to promote change, whereas other issues would see the same professionals as opposing factions. Part of understanding the local political landscape, therefore, involved understanding these ‘dynamic lines of power’ and recognising that political actions are not fixed according to unilateral or bilateral relationships, but rather they function through highly dynamic multilateral relations:

When they [doctors] go with an idea into the trust they have to wade through all the levels of treacle and in doing so they either find a way of circumnavigating the system to get what they want, because they’re used to getting what they want or they’ll just do it anyway and bear the consequences.

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Participants also described the importance of ‘seeing the hidden agendas’ and ‘recognising when people are acting politically’. This was often more difficult for participants to articulate and seemed to rely on past experiences of working with certain people, that is knowing what they typically aim to achieve, or reflecting on the ongoing processes of change to assess the ulterior motives of those one is working with. It seemed to be that more experienced participants were more able to describe how underlying agendas motivate individuals and groups to engage in political behaviours:

You do need to be able to recognise when people are using their political skill to their own ends and potentially negatively and I think that’s something that you need your sort of antennae out for because there’s certainly people who do do that.

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Many participants talked about more generalised forms of strategic thinking. One example was with the need for leaders to articulate ‘clarity of purpose’ when initiating change. However, participants described how effective political action involved not only understanding the problems and solutions driving change, but also, more significantly, the ability to ‘define and redefine’ these problems and solutions in ways that aligned with the prevailing political landscape and with the interests of stakeholders. This aspect of strategic thinking links closely with the communication skills of framing (see Communication and engagement). Linked to this, it was described as important to have a ‘realistic understanding of what is possible’ or what is likely to be successful given the prevailing political landscape. Many reflected on how planned changes were unsuccessful because they had not fully appreciated the opposition of certain groups. As some described, it was important not to waste political credibility on changes that were unlikely to be successful:

. . . that was a challenge, because obviously the clinical side of the team were very blunt in terms of this is how it will be. And there’s more considerations that we had to take into account, in terms of cost, in terms of resources, and a need, as an organisation to develop our own strategy and would make it a bit more sustainable and fit for purpose, going forwards.

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Communication and engagement

The vast majority of participants described communication and engagement skills as key to engaging in organisational politics, which linked to leaders’ ability to both understand and read the local landscape and influence others and reshape the political landscape. The techniques of communication and engagement are well described in the social science literature, and this section, therefore, focuses on those aspects that participants described as especially significant in relation to organisational political and political action.

The ‘art of listening’ was widely regarded as a key to effective communication in general, and political action in particular. Active listening seemed to offer at least three contributions to political action. First, it enabled leaders to better understand the concerns and hopes of individuals involved in, or affected by, change, so that change processes could be tailored or presented in ways to be received more positively (see also below). Second, and moving beyond individuals or groups, active listening was key to reading the local political landscape, especially understanding the lines of power and the likely areas of support and resistance. Third, the practice of listening, or giving the impression of listening, had an additional symbolic function of showing that a leader has shown interest in the concerns of others and that being heard could provide the basis for ongoing and respectful engagement:

Oh, absolutely listen, but really, really demonstrate your listening. Don’t just pretend and pay lip service to it. If you are asking somebody to give you their view, their advice, their expertise then absolutely listen to them and take notice. Don’t think that you know it all and you can do it all better. Ask the people that really know and that really understand and really take notice of it. Really, really listening, I think really listening. . . . People are a valuable asset and people are under a lot of stress and not helped if you’re in an environment where you’ve got all the conflict and problem. I think you learn, you look for the opportunities.

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Complementing these listening skills is the ability to ask probing questions as a way to better read and understand stakeholders’ preferences and their likely reactions to change, and, in turn, to adapt one’s strategies. A number of participants talked, for example, about the strategic use of naive questions, especially when working with new teams or organisations, as a means of exploring how others make sense of their local context and probing (with the perception of naivety) the assumptions that underpin this context. In more duplicitous ways, asking the ‘right’ question was described as demonstrating shared understanding or empathy for the concerns of others, whether or not this was actually the case. In other words, the dual tactics of active listening and asking questions could function as symbolic and presentational strategies of engagement over and above attending to the information provided by stakeholders:

And also, a bit of naivety just to ask stupid questions is very handy.

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A number of participants talked about the importance of not being too directive, but rather being facilitative of two-way conversations and opening up dialogue with and, importantly, among different groups. This could make a number of important contributions to mediating organisational politics. First, it enabled leaders to better understand stakeholders’ different interests, especially to identify mutual areas of interest from which to build alliances. Second, dialogue was seen as creating opportunities for stakeholders to express their concerns, especially their fears and hopes for change, thereby creating a platform for engagement. Third, by opening up dialogue and building connections between stakeholders, it became possible to find ways of empowering people and sharing (or even delegating) responsibilities as a major driver for progressing change. A related engagement strategy was allowing others to ‘shape the agenda’ or giving people the impression that they were shaping the agenda. For some participants, this was seen as a more ‘inclusive approach to change’ that ensured that the best ideas or ‘collective wisdom’ shaped the formulation and implementation of change:

The longer I’ve done it or perhaps in some of the more senior roles is it matters less and less what you think and I think you probably achieve more if you’re prepared to relinquish your own control and that’s more than just delegation. That’s not just about having a team of people that you can give jobs to it’s about being prepared to hear something that’s different to your original plan and acknowledge that that might be a better way of doing it or it might be the more successful route to follow.

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When some participants talked about ceding authority as a form of engagement, there was often an implied assumption that control could be reclaimed, which suggests that perhaps allowing others to shape the agenda was a more complex and manipulative strategy than sometimes implied. This type of engagement strategy created an illusion of influence, usually in the context of seeking to engage relatively powerful groups who ‘need to feel they are in charge’:

I grow whatever they’ve brought to the table, I have the skill set to do that, then bring them back to the table and you’ve got something tangible to show, because they’ve built it they’ve owned it. They then own it and because they own it they implement it.

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In a variety of ways, participants talked about the importance of presenting proposals for change in ways that would be positively received by stakeholders or, more significantly, in ways that could motivate their active participation in change processes. These ideas speak to the concept of ‘framing’, which in the wider social science literature is used to describe how the presentation of an event or situation can influence how an audience makes sense of and reacts to this event. Frames act like ‘frames of reference’ or ‘cognitive schema’ that influence how people filter, perceive and comprehend a situation,147 and, therefore, are potent in shaping reactions to change. 148

A common way that participants talked about such framing was in terms of ‘selling’ a vision of change that would secure the ‘buy-in’ of stakeholders by aligning with the underlying interests and agendas. This involved, first, determining the prevailing interests or concerns of stakeholders before constructing and articulating a relevant set of ideas about how a proposed change initiative would address or align with their agendas:

I mean selling people, staff, the public, whoever, on the list of options you’ve put in front of them, if it is indeed a list. So it’s a question of . . . it’s stopping people coming back and saying, ‘Oh, actually we should do this instead’. ‘Oh you shouldn’t do that, you should do this’.

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In a related way, participants talked of presenting change in ways that not only aligned with or addressed the interests of stakeholders, but also, more significantly, influenced or modified how people understood and reacted to the need for change. This involved more complex and dynamic forms of ‘persuasion’, in which leaders sought to subtly alter the prevailing views of stakeholders by presenting more compelling or convincing ideas about why change was needed. Effective framing required the ability to ‘speak multiple languages’ and to understand the relevant ‘priorities and trigger points’ that will elicit the support of stakeholders. Similarly, framing required knowing what ‘not’ to say and to rerepresent ideas or facts in ways that would appeal to stakeholders:

. . . how can I suss out where I need to influence you? What’s the trigger? Like you said ‘Oh can I?’, so it’s always [chuckling], it sounds awful. It is always being aware, of the other person and what, therefore, what’s right for their organisation?

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It’s not that you’re being deliberately devious or withholding information. It’s just you have to learn what’s appropriate and what individuals want to know. And what they don’t want to know. So that . . . having that support is essential, crucial, vital.

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Another way that participants talked about their framing activities was through the use of particular ‘rhetorical devices’ or strategies, that is stylistic techniques for the organisation and the presentation of arguments with the explicit intention of eliciting a desired reaction. These rhetorical techniques were often linked to particular ‘resources’ (sources of information, evidence or policy) that had certain appeal or relevance to stakeholders:

I think it’s about persuading people that your way is the right way but everyone knows it’s there . . . but one prefers to use influence and argument and logic and empathy and all that, that’s my preferred style of working whereas when one works, as you’re describing, laterally or upwards you’ve got to use relationships . . .

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One approach was the rhetorical ‘use of data’ to justify change, typically based on the idea that such data were objective or independent. The use of data appeals primarily to the logical reasoning or sensibilities of stakeholders as the basis of persuasion. The most prominent examples of this were the use of clinical evidence to engage medical specialists and the use of financial data to persuade those with budgetary responsibilities. There were noteworthy differences, however, in terms of what participants regarded as ‘robust data’, reflective of their professional background or organisational role:

The only thing I can do is be very clear about the numbers, and then, from now on, I keep . . . I will develop very, very clear charts and graphs because I think she might understand a picture, and just keep, ‘this is what we’re doing, this is what we’re doing, this is what we’re doing’.

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Another approach was the ‘use of authority figures’ or the use of those with recognised credibility to endorse change or, in some instances, to persuade others of the need for change. In this sense, authority figures could symbolically represent and legitimise change based on their own standing and reputation, often when the primary leader of change was in some sense lacking in credibility with a given community. For this reason, it seemed that these change leaders reflected on the limits of their own position (self-awareness), while also having a developed understanding of what types of people have credibility with certain audiences (again, drawn from the ability to listen and understand):

There’s always probably someone else who can say it for you. So let them say it for you and then you don’t get all the hassle that goes with it, but it’s been said, the message is there, you don’t have to be the fall guy.

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Participants also talked about using the ‘patient perspective’ or ‘voice’ as a powerful basis of justifying change, persuading others and countering opposition. Many described how a ‘good patient story’ could be more influential in communicating an idea than an abundance of financial or clinical data. For some participants, direct patient involvement in service planning was seen to be important for ensuring that service improvements were organised in the interests of patients, rather than in line with the assumptions of professionals and managers; however, some participants reflected that such patient involvement could be used in more contrived and purposeful ways to counter the views of others:

It’s helping people to see all the time that what we’re doing is the best for the patients and the pathways and that actually it’s not around shifting services, moving services, stopping services, it’s around pulling those services to work together in one system.

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Networks and networking skills

In various ways, participants talked about the importance of social connections, group memberships or other instances of networks as facilitating, and being the vehicle for, change. Participants describe these networks in three common ways. First, it was widely recognised that the pre-existing political landscape of health-care organisation was shaped by professional or interpersonal networks. Second, networks could provide key resources (e.g. people, finances and intelligence) when seeking to formulate or implement change. Third, the creation and mobilisation of networks could help to co-ordinate change activities and counter opposition. These networking skills strongly related to other forms of political action, from strategic thinking and awareness of the local context to communication and engagement activities.

Elaborating these ideas, participants described the importance of identifying and understanding the configuration of stakeholder networks that might positively or negatively affect change. As part of reading the political landscape, this involved a complementary set of relational skills that in many ways resembled the common elements of ‘stakeholder analysis’. 149,150 For example, participants described identifying the different interest groups around an issue, understanding the interests that united and divided them, anticipating the responses to change, appraising their influence, and recognising what resources and support they might offer:

. . . as I say in broader terms, I think that understanding relationships, understanding power, understanding interests, understanding stakeholders, those are all political skills and they’re all absolutely crucial to this job.

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A number of participants talked about their membership of, or access to, such networks. These took two different, but arguably overlapping, forms. The first was access to personal informal networks in the form of connections with influential people or peers who could provide access, support or influence. A number of participants in senior management roles talked, for example, about their peer networks among senior managers working in hospitals. These peer networks provide confidential support and reflective insight when leading change projects, including access to ‘influential people’ or help to ‘work through’ challenging decisions. Some participants described these connections as a source of intelligence to gauge the likely critical pathways to change. In other ways, peer networks could be used as a form of ‘proxy-influence’, in which influential people would represent a person in a setting in which they have limited standing:

So if you build up lots of friendships in an organisation and lots of collaborators then you can make things happen. If you don’t life can be very, very hard. And processes are meant to irradiate that variance but they often don’t because people can use a process to their own end and that can be problematic.

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A second type of network was associated with membership of well-defined professional groupings, in the form of ‘professional networks’. Perhaps unsurprisingly, the majority of these participants were medical doctors whose professional networks were often developed through specialist training or employment within the same organisation, and which provided a strong source of professional identification, peer support and solidarity in the face of change. Less prominent were similar networks for nurses and other health-care professionals. In other ways, participants talked about the importance of fostering and mobilising networks around particular change programmes. These were often presented as ‘alliances’ among people who shared aspirations for change.

Arguably, networking skills are not unique to how people participate in organisational politics, but are relatively common to general forms of strategic management. The activities described resembled many of the steps identified in the wider literature151 and included (1) identifying key people within the local environment; (2) understanding the interests that unite people in a common cause; (3) using relational skills for engaging and enrolling groups in networks; (4) co-ordinating skills for bringing people together; and (5) using skills related to managing conflict and difference within nascent networks. However, participants described network building as a highly iterative and contingent process, with many false starts and overlapping tasks that relied on complementary communication and engagement skills, for example leaders need to frame change programmes with different stakeholders. For many participants, building and mobilising networks was an important strategy for counteracting the influence of established groups or networks that are resistant to change:

. . . so, yeah, I think, 90% of what we do is about brokering conversations between people about trying to find a way to bring people together and to bind them around a common goal and almost being a counsellor between two folk, enabling them to speak.

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Part of the skill of building networks is creating alignments between different stakeholders in the form of ‘common ground’. In many instances, common interests were framed in terms of improving the well-being of patients or local communities. Participants also talked of ‘creating win–wins’ so that all parties felt that they were benefiting from a given change and, therefore, felt compelled to join a collective approach. In another way, the skill of network building was ensuring that the potential losers saw some wider benefit from change or at least some form of ‘compensation’ to motivate their involvement.

Participants also talked about creating alignments through identifying ‘common enemies’. This was much less explicit, but it seemed that, as part of their framing strategies, leaders could characterise a group in negative terms as a means of galvanising support. To some extent, this seemed to reflect deeper cultural differences or ‘fault lines’ between hospital departments or health and social care sectors, and stemmed from underlying notions of ‘them and us’.

Another aspect of network building involved drawing on ‘key people’ to help to co-ordinate and champion group activities. As one person suggested, ‘a lot of the times we target people for things that we need doing’ (WP2–1). As mentioned above, participants talked of using ‘authority figures’ to endorse change and, in a similar way, some talked about recruiting ‘champions’ who could advocate for change within areas in which a project leader might have limited influence. One important, but largely under valued, example was the role of the ‘first-follower’ or the individual who supports an emerging network:

. . . that’s really important and having a safe group of people that you can do that with be they in your work situation or ideally some sort of action-learning group that you can draw on, someone that you can pick up the [tele]phone to where you can reflect.

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Relational strategies and tactics with ‘difficult’ groups

The final theme describes the relational strategies and interpersonal skills used, in concert with the above strategies and actions, in more direct instances of interpersonal influence. These represent a relatively discrete set of skills that in many ways deal with the ‘sharp end’ of organisational politics, especially the ‘face-to-face’ encounters, with influence and persuasion, as well as coping with resistance and hostility.

Many participants spoke about dealing with ‘prominent’ individuals or ‘egos’ who had significant sway among clinical teams and could often be outspoken opponents of change. These people tended to benefit from high standing within their professional community and workplace, and were often presented as defending the status quo or advocating for certain types of change that would safeguard ‘their’ professional standing (when ‘their’ could be personal or professional). These prominent people were the focal point for resistance around which others coalesced. For this reason, it was seen to be necessary to deal with these people. The most common approach was to open up dialogue and actively listen to such people (as described above), but less as a strategy of listening and learning and more to give the impression of engagement and to win them over. It was seen as important to pinpoint the particular interests that mattered and find ways to allay their concerns (or at least to give the impression of this):

We had to go and smooth some egos. I remember having to go to one of our trauma units. There was myself, the medical lead and the chief operating officer of the hospital who met with a senior doctor and thinking that we were meeting with the senior doctor, but when we got there we were met with a barrage of the senior doctor plus his team, I think. There was something around smoothing the ruffled feathers.

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When seeking to influence powerful people and groups, participants also talked about the purposeful strategy of empowering others. In some ways, empowering stakeholders was a way of reducing or containing conflict by enrolling recalcitrant groups within change processes, even if this was in only a superficial way. That said, some participants described their leadership style as explicitly facilitative, with the aim of supporting others to become more skilled and capable of implementing change for themselves, thereby suggesting a less manipulative view of empowerment:

. . . very much delegating and working to people’s strengths . . . encouraging others to take the lead, ensuring what happens is right rather than who decides what happens. So it’s terribly important that the right thing happens rather than them looking to the boss.

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The ability to delegate tasks and empower others was seen to be part of a dynamic strategy. On the one hand, it was presented as a way of securing the involvement and commitment of stakeholders through encouraging them to shape or own change processes in ways that reflected their interest. On the other hand, these delegation strategies were useful for distributing tasks to key actors or opinion leaders based within clinical teams or communities with whom leaders might have limited influence.

More experienced participants talked of the importance of ‘confronting and challenging’ influential individuals who repeatedly blocked change. Before attempting this, it seemed to be important to both determine ‘the red lines’ or critical issues that needed to be achieved and ‘[pick] their battles’ so as not to expend political energy on lost causes. Significantly, the capacity to challenge and influence people and groups was clearly predicated on a person’s self-determination and, importantly, formal position or status within the workplace. For this reason, it was more common for senior managers to talk of challenging powerful clinicians:

[It’s] being able to stand up and say ‘I think you’re wrong, and this is why’, is just as important as you know, being authentic and all of that, so it’s like the thing about [inaudible] is quite uncomfortable, so like being uncomfortable is not something we like doing, because it’s uncertainty.

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Nearly all participants talked of strategies and tactics for negotiating with different people. Effective negotiation skills were informed by the complementary skills and behaviours described above, especially the ability to listen and understand the stakeholders’ preferences and the ability to frame change in persuasive or compelling ways. The negotiation tactics that were used tended to fall into one of two approaches. One approach was to identify trade-offs and ‘deals’ that would satisfy the expectations of a given group as part of an overarching engagement strategy. This might involve, for example, offering additional staffing resources, finances or access to technologies for participating in a new service model. In this regard, it seemed to be important to first determine what the other party wanted in return for their support and then to secure this item as part of a ‘trade’. Another approach was to offer ‘compensation’ when change negatively affected a group as a way of maintaining their support. In general, these negotiating skills were described as highly interactive, involving ‘offers and counter-offers’. Importantly, these interactions were rarely part of the formal change process, but rather were conducted through ‘informal channels’, possibly with a view to protect the reputation or ‘face’ of both parties:

I think there’s a lot of what you would call back stage or behind-the-scenes conversations, so building, firstly trying to build relationships with peers . . . to say ‘OK this is happening to me, I’m raising it’, and they would go ‘yeah, I had one of those, but I’ve just tried to deal with that,’ you would build a coalition.

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In other ways, participants described interpersonal influence as being manipulative. When reflecting on their career, for example, some participants recounted instances in which they had felt unduly pressured into accepting a situation that was not necessarily in their interest. Significantly, participants with more developed and senior careers reflected on how they had used techniques to influence and manipulate people when seeking to introduce change. For some participants, these activities were self-serving and reflected personal career ambitions, whereas others described how they were commonly used as part of other engagement strategies, especially when empowering others. Although many participants recognised that forms of manipulation were widely used in the health sector, and that manipulation was arguably a key part of political behaviours, few actually endorsed or admitted to using forms of manipulation. This may illustrate their attribution bias or desire to present a positive impression with the interviewers:

In the organisation you get very politically astute people who . . . I would . . . yes. Calling it ‘political astuteness’ in these people is a euphemism for being manipulative . . . that is knowing how to play the system to get their own way . . . What’s good for them, for their careers . . .

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Although interpersonal and relational tactics were typically described as operating through informal channels, some participants highlighted the interdependencies with the more formal organisational structures and processes. An important point to make is that the scope to use more formal organisational processes is inherently conditioned by a person’s formal role and authority within an organisation. Many narratives described the need to ‘move between the formal and informal domains’ of managing change, which inevitably involved understanding how best to work within the formal structures and when to move into the more informal realm. This could occur, for example, when ‘hard’ formal authority could be used by those in authority to block change:

What’s the bureaucracy you have to step through to be able to talk to. So at that point in time it was still very hierarchical. There’s still degrees about there now. I don’t think it’s as bad but back in 2007–8 when this all started to emerge for me you weren’t allowed to go speak to without going through the chain of command otherwise that tended to upset a lot of people.

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Interestingly, participants also said that effective political action could involve ‘creating formal structures’ to help to implement or sustain change. For example, some participants talked about drawing on formal authority to stipulate or enact change, while others described how their ‘formal’ control of resources could be used to create incentives and inducements to win over difficult groups:

I think there’s something about, forming formal structures. Often being straightforward personalities, I think being fair and firm so whatever it is . . . I know it’s really dull but it’s not really dull is it?

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Illustration 1: the politics of competing visions for regional system transformation

Case one focuses on the challenge of creating a shared vision or sense of purpose for what a given STP aims to achieve in the overarching ‘strategic arena’. The diversity of constituent groups and complex governance arrangements meant that it was often difficult to establish a shared sense of purpose that all relevant stakeholders could align with or work towards. Most participants described the purpose of the STPs as a positive development for health and care system reform; however, beyond the broad ‘headlines’ around more place-based integration, STP plans could easily be interpreted as too broad and imprecise or as reflecting the narrow views of relatively dominant regional actors. In two STP case studies, determining and articulating a coherent and inclusive vision of change was an initial, and to some extent ongoing, hurdle in the transformation process that brought to light a key focus for political controversy.

This case describes how one ‘core’ STP executive group worked to craft, articulate and reinforce a shared vision of system change that reflected the overarching goals set out by the STP board and could provide a coherent sense of purpose and orientation for local project teams involved in implementing change. The case focuses on the changing strategy of this core executive group in its relationship with regional stakeholders and its attempt to move from a focus on managing the ‘harder’ aspects of system governance to a focus on the ‘softer’ side of values and purpose, which would better secure stakeholder buy-in for change.

A significant feature of the ‘core’ group’s approach was their commitment to self-reflection (or group reflection) in terms of their position in the system and contribution to system transformation. In terms of ‘self-reflection’, this included a, somewhat paradoxical, view of their liminal position within the care system, that is operating between statutory organisations and having little formal authority, and yet at the same time having delegated authority from the senior STP leader to authorise, co-ordinate and oversee system change initiatives. For this reason, much of their early activities focused on establishing workable governance arrangements that clarified their position, rather than the more symbolic or values-based aspects of change:

We are in a precarious position. We are a small team and we don’t really fit anywhere, but we are responsible for making sure the plans are taken forward.

Field notes: STP project lead

In taking forward the STP plans, the group further reflected that regional stakeholders often held different views about what system change aimed to achieve. As members of the core group reflected, regional stakeholders might easily embrace the broad principles of system change; however, when this this had an impact on their finances or service levels, the prospect of system change became problematic:

They might think system change is important in their hearts but not necessarily in their heads.

STP leader

It was through such reflective understanding about both their role in the system and the difficulties of securing stakeholder buy-in that members of the executive ‘core’ group recognised the need to change their approach and refocus their efforts away from managing the administrative structures to determining and articulating a shared sense of vision and purpose that stakeholders could more easily align with and support. The core group discussed how regional partners had distinct interpretations of system change, which were shaped by their particular service context and recent history of funding. For example, it was suggested that the view of system change held by local government partners was shaped by their prevailing financial constraints and service pressures, and the party-political priorities of formal political leaders. By contrast, commissioners were seen as understanding system change as a potential opportunity for cost saving and efficiencies. For this reason, it was necessary to create a new ‘system view’ in which stakeholders recognised that by ‘individually giving up a little, we gained a lot more as a system’ (STP lead).

In crafting a vision for system change, the executive group focused on four linked communicative and framing elements. The first was to be clear about ‘the who’ and ‘the why’ of change, specifically to foreground the health needs of local people and communities as the ultimate beneficiaries of system change:

We have got to remind people why we are doing this. The people of [place] deserve a better care service.

Field notes: organisational development lead

Linked to this, the second element was to emphasise the values and moral imperative for system change, by being more explicit about the normative standards of doing the right thing for patients. The third element was to be clear about ‘how’ system change would meet these needs and deliver the desired improvements. A prominent idea discussed among the core group was the need to ‘help’ (or encourage) stakeholders to ‘see the big picture’, especially the idea that by ‘giving up a little we can achieve more important and far-reaching improvements in the long run’ (STP lead). The fourth element was a focus on language and using the words and terms that speak to the different stakeholders. On one level, this related to selecting and using appropriate routine service data to demonstrate particular problems, and on another level drawing on powerful patient narratives to justify the vision. For example, recent innovations in the integration of community and care home services were widely described in terms of the impact on patient experience and well-being.

In reinforcing this recreated vision, the group highlighted the continuing role of formal governance structures to reinforce and (re-)incentivise engagement in system change. In particular, the vision was aligned with new commissioning arrangements that similarly took a regional perspective, together with longer-term plans to develop the STP into integrated care systems with enhanced statutory responsibilities for system change. In other ways, the executive group promoted the vision of the system by working more closely with public and community groups to reinforce the values and benefits of system working. This included, for example, partnering with prominent sports clubs, employers and voluntary groups to contribute to directly supporting change through hosting community events, and also being vocal in their support for more systems working:

We have been working with [team name] for a few years now as part of our community outreach programmes. They have helped us organise and deliver events and they have helped us get the message out in ways that probably makes more sense to the people of [place].

Field notes: project team lead

By reflecting on their position and activities to date, especially recognising the limits of their influence, the executive group worked to reframe the vision of the STP in ways that focused more on the symbolic or normative aspects of system change rather than on system governance. This was framed through alignment with both national and local priorities, especially the needs of local communities, and it was reinforced, somewhat paradoxically, through re-emphasising the changing role of formal governance structures (Box 1).

Illustration 2: the politics of stakeholder engagement in system transformation

This second case focuses on the politics of stakeholder involvement in the design and transformation of ‘system architecture’, specifically the reconfiguration of regional care commissioning. All three STP cases talked of changing the overarching ‘architecture’ or ‘design’ of their care system, which usually referred to reconfiguring the prevailing organisation of services and distribution of resources held by individual organisations, so that they better addressed the needs of local communities. As illustrated above, a key challenge of any system transformation process is securing the meaningful involvement of stakeholders across the stages: the design, specification and implementation. National guidance suggests that, alongside patients and the public stakeholders, ‘clinicians should determine and drive the case for change, based on best available evidence’155 (contains public sector information licensed under the Open Government Licence v3.0). By ensuring that change processes are shaped by stakeholder involvement, change can be expected to have greater relevance and, importantly, legitimacy with such stakeholders.

This case illustrates the politics of engaging clinicians in system change. It focuses on one STP’s experience in reconfiguring its multiple commissioning organisations into a single regional body [Clinical Commissioning Group (CCG)] that mirrors the footprint of the overarching STP with the goal of offering more strategic system-wide commissioning. This case examines how system leaders from the STP and CCGs engaged general practitioners (GPs) in this process. This case focuses on the interactions between, on the one hand, CCG leaders and the ‘engagement group’ within the STP and, on the other hand, GP leaders and representatives from across the region.

It was reported that managers from the region’s multiple CCGs started planning for a type of merger in the early days of formulating the STP and, significantly, long before any consultation strategy was considered. For CCG and STP leaders, change seemed inevitable and aligned with national policies and, therefore, the rationale of stakeholder engagement was less about co-designing change and more about securing support. Although CCG managers talked of undertaking preliminary engagement activities, it seemed that these activities involved largely informal conversations with GP leaders:

. . . you can’t swim against the tide . . . staying as we are would not directly align with the national direction for the NHS . . . We need to operate at a ‘system’ level across the entire geographical area.

Field interview

A more formal engagement strategy was developed that included (1) the preparation and dissemination of a proposal document; (2) a website and communication campaign directed to local GPs, patient groups and third-sector groups; and (3) an online survey with public and professional representations. GP stakeholders raised questions about this approach, describing it as relatively superficial or at best ‘information giving’, which led to an extended consultation plan, including (4) public engagement events or ‘town hall’ meetings, (5) focus groups with stakeholder groups and (6) a ‘listening exercise’ with GP representatives from across the CCG areas.

The communication and framing of both ‘system change’ and the engagement strategy seemed to be concerned with giving the impression of an inclusive and legitimate decision-making process.

The framing strategy focused in particular on the anticipated benefits both to the wider public and to clinicians and clinical leaders, such as saved clinical time, stronger clinical voice and reduced management. This could be further seen in the idea that there would be a series of ‘must-haves’ whatever the outcomes of the engagement process, which included strong clinical leadership. However, a contrasting policy narrative was that change was part of a bigger agenda, so there is little point in opposing it.

The reactions of GPs were directed at the details of both the proposal and the engagement processes. Some GPs actively questioned key procedural aspects of the overall decision-making process in public meetings, seeing decision-making processes as a fait accompli. For example, a number argued that senior CCG managers had effectively agreed the proposal long before the consultation was planned. The majority of our interviewed GPs described the decision as ‘top-down’ and the consultation processes as ‘tokenistic’ and a ‘rubber-stamping exercise’; such views underpinned a shared concern not with the substance of reform but with the way that change was being introduced:

If they had done [the consultation exercise] before they merged the governing bodies it would have looked more like a consultation and less like a foregone event.

GP1

It’s been too little too late. We’ve been told that it’s happening but we’re not told that we could have a vote on it till very recently.

GP4

They haven’t . . . the consultations were a couple evenings . . . most GPs are too busy to attend in the evenings . . . anything you put on in an evening is not going to engage people.

GP5

Despite this, the majority of GPs involved in the study described the proposed merger as having both administrative and clinical advantages. In particular, it was suggested that the new CCG arrangements could lead to more strategic commissioning, especially for planning services at the regional level and for countering the dominance of NHS trusts in determining service models:

The CCGs will become more of a strategic commissioner . . . if it works it’ll be fantastic.

GP8

. . . it will give a more strategic overview of the system and CCGs with a smaller footprint will have a small voice. A larger CCG will have greater power as they are negotiating on behalf of a large population. . . . The larger commissioner might have more power over the large hospital than we have.

GP9

Some GPs raised concerns about the proposed changes, illustrating this with counter arguments and rhetorical framings. One common view was that change was motivated less to improve decision-making, strengthen clinical voice or improve care outcomes, as implied, and more to reduce administrative duplication and create more standardised models of work. Others argued that regional commissioning could neglect and, over time, diminish the expertise of local commissioning processes. Challenging the message set out by CCG leaders, GPs saw reduced opportunities for their involvement in commissioning, or at best clinical leadership being tokenistic. The response from many GPs was that they would not actively engage in the new commissioning arrangements and that they would instead invest their energies in new clinical leadership roles within their GP practices or primary care networks (Box 2). For this reason, parallel system changes facilitated disengagement and diverted professional attention away from commissioning:

It’s a distraction from health care. Our jobs stay the same but it’s just rearranging the deck chairs on the Titanic.

GP2

There are other ways we can bring about the needed changes in care . . . the PCNs [primary care networks] should become much more focused on the needs of local communities.

GP3

Illustration 3: the politics of sharing resources for new system architecture

Case three focuses on the combined challenges of redesigning ‘system architecture’ and, by implication, encouraging system actors to share resources (e.g. staff, finances and buildings) to enable more integrated ways of working. As with the other STPs, system redesign involved, for example, redistributing roles and responsibilities, merging organisations, replacing organisations, and changing the boundaries and connections between organisations. Each of these represented a site (or microsite) for the broader politics of system change, especially when it involved sharing or redistributing scarce or specialist resources.

This case illustrates the challenges of sharing resources when redesigning children’s services, family services and maternity services within one STP. The intention of the new architecture plan was to create more integrated and holistic care for children and families in the early years of life. The proposed plan comprised a programme of transformation projects that involved the redistribution of hospital and community maternity services and the creation of multiagency regional ‘hubs’, which required the distribution of roles and resources among hospital and community services, as well as primary care and local authority care services.

As above, an initial controversy was with the vision of system change. Although the overall idea of integrating a more seamless service was understood, it was difficult for all stakeholders to share an understanding of what change would look like, how stakeholders would work at different levels and where responsibilities lay. It was also unclear how individual transformation projects, some of which preceded the idea of system reconfiguration, would fit with the new model of care:

But, you know, ah, but we’re in it together. Ah, no, but we’re not. So there’s still this push/pull about are we in it together or aren’t we in it together? What are you responsible for? What aren’t you responsible for?

Clinical lead

A significant complication related to the allocation and sharing of financial and physical resources. In terms of financial resources, a major issue related to how new ways of working would align with prevailing financial governance systems. Although commissioners were broadly supportive of a new integrated model, there was uncertainty about how proposed services should be commissioned, especially in terms of who would control the resources in this multiagency framework. The second related to the control of physical estates, for example hospital buildings, because the proposed system architecture plan involved introducing new community ‘hubs’ located in NHS and local authority venues, but on the basis of shared responsibility. This highlighted additional complications, such as the infection control requirements of different care sectors:

We’ve been round to all the (STP) locality meetings and had discussions at their boards but I don’t know whether we’ve progressed it anywhere really. I don’t think it’s moved. It’s still the same issue. Where is the money coming from? It’s difficult.

Clinical lead

. . . it is quite different you know, in terms of the traditional way of delivering hospital services and I think, support, and more looking at how we shifted from the funding from kind of the community providers into the voluntary sector to do some of that intervention.

Project manager

The approach taken by system leaders, comprising members of the STP executive group, the locality partnership group and the thematic programme board, was seemingly unplanned and messy. Based on a history of interagency tensions, the change process became protracted and riven with conflict, with little overarching strategy or immediate success. For example, the Child and Adolescent Mental Health Services felt marginalised by the ‘saintly’ maternity services. One of the first strategies adopted by the executive group was to open up dialogue with constituent organisations with the dual aims of listening to their concerns about the prevailing model of care and, simultaneously, encouraging them to recognise the potential benefits of system change. This led some stakeholders to feel that they had come up with the rationale of system change rather than it being imposed. As part of these engagement activities, leaders also talked of developing a better understanding of the interests and agendas of regional actors, especially around the control of resources and the tensions between hospital- and community-based services:

It’s just building up that . . . I suppose if I was working in an office I’d have a better relationship with them, or a worse one. Depends. It’s all about personality at the end of the day . . . It’s just building that rapport up with the person that’s leading the project and I suppose it’s about telling them . . . you know, because everything’s to do with performance reporting or performance management, you’ve got to take out the fact that I’m not there to beat them with a stick, you know it’s beneficial for me and the person running the project to get the information that I need to help them run that project.

Project manager

A subgroup of system leaders, drawn from one of the region’s children’s and family services, proactively worked to mediate the tensions between regional organisations about the redistribution of roles and resources. Building on the above, this involved fostering dialogue among local organisations so that they could better understand their respective priorities and explore how differences could be resolved through a systems approach. On a personal level, leaders recognised that the situation was complex and emphasised the importance of persevering in fostering mutual understanding. Interestingly, some participants described how system leaders adopted a particular style that perhaps reflected the ‘maternal’ character of their profession, in that they sought to defuse conflict, promote a calm approach and nurture a supportive environment:

. . . it feels like you could not have ridden this sort of tide if you need everything very orderly and in a box, kind of thing, because it just feels so unlike that at the moment. We’re constantly adapting to whatever the next thing is.

Project manager

Although progress was made in resolving local tensions, system leaders opted to contract a management consultant to facilitate the co-design of the new system architecture plan. This highlighted three significant turning points. First, leaders recognised and advocated for a co-design approach so that stakeholders could see and feel that change was based on an open and deliberative approach. Second, the employment of an external consultant perhaps suggests that local leaders recognised their lack of specialist skills in co-design methods. The third turning point was the importance of being seen as neutral or not embroiled in local politics:

. . . the local authority has funded a management consultant who’s working with the senior teams, so we had a workshop last Friday. We’ve got a workshop again tomorrow. So it’s moving at quite a pace developing and thinking around what would integration look like? What’s the [unclear] culture? . . . What type of roles should be integrated? What functions are definitely one or the other?

Clinical leader

Through this process, participants described how a ‘bottom-up’ approach to system change emerged that reflected the local interests of stakeholders and emerging evidence of effective system change; however, to some extent, the eventual model of system change continued to reflect the outlined specification previously set out by system leaders (Box 3).

Illustration 4: the politics of competing priorities for transformation

The STP programme boards appeared to function in the middle of the STP structures, working to translate the broad strategic plan for system change into a more specific programme of change within discrete service areas, for example maternity or mental health, that would then be operationalised by individual project or transformation teams. An initial task faced by these programme boards was the elaboration of the overarching aims for system change and population health improvement into specific and operational priorities for change. This case illustration describes the experiences of one urgent care programme board as it worked to determine its strategic priorities. This case highlights the political skills, strategies and actions of the designated programme lead (PL) in working with others to identify, mediate and reconcile competing viewpoints and preferences.

In setting the context for group discussions, the PLs would often restate the ‘big picture’ of system change, rearticulating the expectations from the STP and promoting shared values or a sense of purpose for system change. They also worked to ‘open up dialogue’ and debate among board members to explore the problems and issues facing urgent care, especially by encouraging stakeholders from outside the acute hospital sector to contribute to the analysis of the challenges facing urgent care, such as primary, community and mental health services. This helped to create a more nuanced and shared understanding of the issues from which subsequent proposals for change could be appraised:

It’s about being inclusive . . . so people can feel engaged and inspired . . . I know how difficult it can be to try to force people, doctors, to accept change and it has to feel that it is driven by the community.

Field interview

As deliberations continued, the PL tasked opposing groupings to develop and evidence their priorities and proposals for system change. This involved drawing on the expertise of the CCG representatives (as people more accustomed to reviewing business cases) and the STP management representatives (as people with insight into other programme themes) to articulate the expectations and requirements of these proposals. This strategy of ‘delegation’ seemed to pause or defuse debate by suggesting that ‘more work was needed’ to understand and evidence the issue before carrying on with deliberations. It also enabled the PL to identify nascent project teams around shared interests and to continue the strategy of delegation. In reviewing these proposals, the PL often advocated the importance of ‘data-driven decision-making’ or establishing a robust set of measures on the urgent care system from which to identify system challenges, prioritise change and, in time, evaluate improvement. This was presented as a more objective and technical basis of prioritisation than relying on group debate within the programme board:

The PL asks the lead for the ‘Street Care’ project [name changed] to give an update of the development of the proposal. The Street Care lead [from the community mental health team] reports that he has been in contact with the police service community liaison and mental health leads, and also the ambulance services, to identify potential sources of data. The PL asked how they intended to use the data, to which the project lead talked about better understanding the numbers of people needing primary care in public spaces.

Field notes

When dealing with conflicting perspectives, the PL seemed skilled at keeping people ‘at the table’ or discouraging their disengagement from the process. It was described how the PL met with people ‘outside the meeting’ to defuse disagreements, reconcile differences or find inducements that would maintain their involvement:

It’s so important to find the things that will keep them interested, it doesn’t always have to be more resource or pandering to their egos, it is better when it’s about the issues that really matter to the service and communities.

PL

In seeking to move beyond conflict, the PL seemed to adopt a strategy of ‘sufficient consensus’. This involved developing some degree of collective consent for a given priority and transformation project that the PL would then authorise with additional support from the STP management representative and the CCG lead. Although this gave the appearance of enhanced deliberation and inclusive decision-making, it still seemed to suggest that authority mainly rested with a smaller group of people who, however, still needed the involvement and support of the wider group of stakeholders.

One reading of this was that the PL was committed to a more deliberative and democratic approach to decision-making that would lead to greater legitimacy and commitment among system stakeholders. However, a more critical interpretation of these activities suggests a slightly different set of political intentions, skills and activities. First, the PL seemed to use their opening remarks on the ‘big picture’ to frame or ‘set the agenda’ for debate around which a common viewpoint could be engendered. Second, this initial framing had the effect of also positioning the PL in a relatively distinct position to other board members in that they had a more developed understanding of the ‘big picture’ because of their involvement in ‘higher-level’ strategic decision-making. Third, the PL was able to better understand the areas of alignment and disagreement, which informed their subsequent engagement activities. Fourth, the deliberative process gave participants a sense of having influence on the decision-making process, even if they did not (Box 4).

Illustration 5: the politics of team dynamics and (mis-)reading the political context

All STP transformation projects needed, in some sense, to appraise the political context of designing and implementing change. A small number of teams engaged in more explicit discussions and assessments of the lines of power and competing interests that would probably have an impact on their project work. Most teams, however, seemed to engage in more ad hoc and informal discussions about such issues, and often relied on implicit assumptions that were not clearly shared by other team members. This case illustrates the dilemmas faced by one project team as it worked through the different ways that its team members ‘read’ and made sense of the diverse and competing interests among wider stakeholders.

The case focuses on a project team that aimed to introduce personal health budgets (PHBs) for people diagnosed with personality disorder. The broad rationale for the project was to enable people diagnosed with personality disorder to identify and acquire more personalised support to meet their psychological needs and, in turn, to reduce the demand on acute mental health services. This project team comprised six people: the deputy chief nurse from a mental health NHS trust (who acted as project lead), a senior medical representative from the same trust, a STP lead for personalised care (seconded from one of the region’s CCGs), a representative for mental health commissioning from another CCG, a representative from the local authority adult mental health service and a representative from a patient advocacy group. It became clear during their initial project meetings that these team members held differing views about the levels of support or interest among wider system stakeholders for this initiative.

Differences in how project team members appraised the preference and views of the wider care system shaped both how the project team members worked together and how they worked with external stakeholders. It was clear that these differences in understanding within the project team stemmed from team members’ primary affiliation or role in the wider system of care. For this reason, the case elaborates a key internal political challenge for multiagency project teams that stems from their reading of the external political landscape:

Unlocking funding is the challenge, when you get down to it, everyone saying, well social care are saying the funding should come of the trust, and the trust is overspent and it’s running out of beds. So, we have got to make argument that if we spend a little bit more we could bring that overspend down . . . If we can overspend . . . but on things that are helpful for people that is better than spending on private providers out of area.

Project lead

Specifically, project team members appeared to ‘read the local political environment’ in two contrasting ways. Those from the NHS trust saw the main obstacles to introducing PHBs to be a lack of understanding among front-line health and social care staff about the potential benefits to patients, and relatedly their lack of ability to assess patients as requiring PHBs and supporting them to make use of their enhanced financial autonomy. For these team members, it was imperative that community health and social care teams were supportive of the scheme and able to fully support its implementation with patients:

Clinical, strategical and vision it is absolutely the right thing to do . . . But internally, I haven’t got the trust to identify any funding, something has come via the CCG for a small number of patients. Whilst the money seems to be the block, I don’t really think it is, I think it is the resource in terms of capacity and frontline [NHS] staff to engage with it. We want to try it as proof of concept.

Medical representative

By contrast, team members from the STP PHB team, the local authority and the patient advocacy group saw specialists and leaders from the acute NHS trust (and to a lesser extent the CCGs) to be the primary obstacles to change. This coalition of team members held the strong view that the NHS trust would oppose the introduction of PHBs because it would potentially divert patients and resources from the acute statutory sector. In other words, local organisations for which representatives were not only part of the project team but also leading the project team were seen as the primary barriers to change:

It’s not that they don’t understand personal budgets. It’s that they don’t really want them in their [emphasis] clinical service. They see it as diverting resources.

PHB lead

The project team’s differing perceptions and viewpoints underscored a lack of shared purpose and, more significantly, complicated team dynamics. Several team members described team meetings as disorderly and disrespectful, with people talking over each other and not being prepared to listen to different perspectives:

I have never been in a team like it. Everyone just talked over each other, there is no dialogue.

Project lead

A major internal political challenge was to reconcile these differences and to establish a shared sense of purpose. This involved, for example, agreeing to take part in a series of team-building activities to improve interpersonal relationships and fostering more open dialogue outside formal team meetings to explore team members’ different perceptions of the issues facing mental health services.

In parallel, the PHB lead took a more proactive, unilateral or ‘breakaway’ role in moving forward project work, without the direct or full involvement of all team members. This could be described as a patient-centred engagement strategy that aimed to work directly with service users to test and develop the evidence for the new service model; this is evidence that could then be used to persuade both internal and external stakeholders. This involved three strands of activity. The first strand of activity was to carry out a preliminary assessment with patient representative groups of the anticipated needs and benefits of PHB, especially what types and levels of services might be wanted by people, that is to gather the patient perspective. The second strand of activity was to undertake a short evaluation of the PHB scheme for a small community of people with a diagnosis of personality disorder, that is to develop the evidence. The third strand of activity was the formation of a small patient representative group to champion the implementation and use of PHBs among relevant service user groups but also to represent the experiences of patients with key strategic decision-makers:

We know PHBs work for other communities, and we really need to find the evidence that they can work for people with personality disorder. We need to show the outcomes for people can be better and that there are potential savings to the system.

Field note: PHB lead

Despite these activities, the PHB project was paused and then discontinued because of system pressures brought about by the COVID-19 pandemic. One reason given was that it would be difficult for people to access non-statutory services during lockdown conditions and another reason was that project team members needed to return to their primary clinical or organisational duties during the pandemic. However, another reading could be that the pandemic provided the rationale or a changed context to close down a potential innovation that, according to the PHB lead, was not a priority or well received by prominent actors in the regional care system (Box 5).

Illustration 6: the politics of implementing integrated acute and primary care services

Each case study STP had plans to introduce more integrated ways of organising and delivering services. Such integration is typically premised on the idea that existing models of service organisation can be fragmented, wasteful of scarce resources and poorly suited to address the complex care needs of people and communities. For this reason, the integration of care aims to achieve more high-quality patient-centred care, as well as resource savings through supporting care providers to work in more co-ordinated ways.

One prominent model of integration is when multiple health and care service provider organisations involved in the delivery of different aspects of care within a given new locality are brought together into a single, more streamlined and co-ordinated, entity. In practice, this involves creating a layer of operational and financial governance to oversee and co-ordinate the activities of primary, secondary, community and social care organisations, including new ‘vertical’ lines of accountability and co-ordination, as well as new ‘horizontal’ pathways for care delivery.

This illustrative case focuses on the political controversies surrounding the introduction of a new locality partnership organisation that aimed, in broad terms, to provide referral processes and continuity of care, as well as other forms of functional integration of non-clinical administration, such as information systems, by bringing together a large NHS (acute) trust, a GP federation (of multiple GP practices), local authority social care providers, and private and third-sector care providers. Significantly, this resembled a form of ‘vertical’ integration in which one organisation (the NHS trust) was designated to oversee and manage the overarching ‘supply chain’ of locality care pathways from referral to hospital care to community care, with the anticipated benefits of reducing transaction costs and streamlining interdependent ‘production’ processes. This case study is important because it reflects the awareness, skills and groundwork that is required to understand and deal with divergent interests and move the change from a position of impasse to a position of agreed objectives and outcomes. In addition, the case is interesting because it shows that the groundwork is both ‘front stage’ and ‘back stage’.

The primary issue faced by the project team (comprising service leaders from the STP executive, the local CCG, the NHS trust and GP federation) was a breakdown in relations between local GPs and the NHS trust when the integration was proposed by the STP. Despite a positive history of close working between primary and secondary care providers, the planned integration appeared to fracture this working relationship and destabilise the balance of power in the locality. GPs perceived that the proposed arrangement gave too much influence and power to the NHS trust:

. . . and it really quickly became apparent that nobody was on the same page, you know, there was no agreement about what the priorities were, they, the contract actually wasn’t that good, there weren’t many safeguarding measures in it, so we didn’t know what was going on in the services. Letting the contract to the acute provider, put the acute provider very much in the driving seat. And there was . . . I suppose within 6 months, it was really apparent that the GPs were . . . all on the same page about what they were going to deliver and how they were going to do that, and there was some big falling outs, big arguments.

Senior STP leader

A number of GP leaders argued strongly that hospital managers did not understand the value of primary care and that there was a risk that many of the advances made in primary care could be lost if services were transferred back to the hospital sector. GPs also saw such change as having a negative impact on their finances that were dependent in part from providing certain services. Such tensions were manifest in interpersonal behaviours in project team meetings in which, for example, there was clear confrontational and accusatory behaviour, with stakeholders unable to agree priorities and becoming distracted in their arguments as they debated preferred governance arrangements. In many instances, these debates reinforced sectoral boundaries and identities.

In taking a new approach (or changing tack), the project team decided to appoint an independent chairperson who could help to mediate relationships from an impartial standpoint, while also appointing a new project lead (a CCG finance director) who was able to ‘wear two hats’ and understand the details of contracting and procurement across the primary and secondary care boundary. Working together, in a conjoint way, these project leads talked with local stakeholders about the importance of seeing the longer-term benefits of change and persevering to resolve the tensions in the relationship between GPs and the trust. This involved adopting a more open and deliberative approach to stakeholder engagement, in which representatives were encouraged to ‘see the world from the other’s perspective’. This seemed to play on reading and empathising with the heated emotions that stakeholders had around change, for example understanding their fears:

[S]ome of it’s been about developing relationships and alliances . . . getting a better, clearer, shared understanding across the different stakeholders about the current situation and what the facts are and what the evidence is, and what needs to change.

New project lead

As part of these activities, the leaders targeted key people of influence from the respective organisations to develop a better understanding of their particular interests and concerns to devise targeted solutions that could win their support. This involved exploring forms of change that would benefit all parties through negotiated forms of ‘give-and-take’ or identifying ‘win–wins’, such as creating more flexible joint contracts for GPs. It was reported that these influential people worked ‘behind the scenes’ to build more trusting and collaborative ways of working among stakeholders. One prominent example was to encourage stakeholders to recognise that defunding social care or primary care would ultimately have a knock-on effect of increasing demand on emergency services; therefore, it is in the acute trust’s interests to maintain support for community services. The subsequent endorsement and support of these people helped to consolidate group deliberations. The learning from these activities was then brought back to subsequent project meetings to inform decision-making and often counter the views of recalcitrant groups:

. . . and it won’t necessarily always be around even the main board table. There are sub-boards and there are other things out there . . . So we don’t get hung up on the mechanics.

GP representative

The study also found that the project leaders were open about their capacity to use more formal authority structures to enforce change in the absence of finding agreement. Although reluctant to use this option, leaders from the CCG talked of using their financial controls to take services away from the trust and either find alternative secondary care providers or explore the potential for more primary care provision. This type of ‘nuclear option’ was rarely used but mention of it seemed to refocus the attention of the NHS trust leaders by demonstrating the underlying lines of formal authority and the inherent interdependencies:

. . . in terms of leverage, then that acute trust knows that, the commissioner is prepared to take another chunk out of it if it doesn’t behave.

STP senior leader

Over time, the barriers to integration were overcome by a combination of strategies concerned with relationships and alliances, communication, and self and style. The element of neutrality of the network chairperson seemed to be important to gain trust and they used a personal style that helped to push beyond the controversies with an empathetic but emphatic approach (Box 6).

Illustration 7: the politics of implementing integrated specialist services across acute and community boundaries

Following the above case, this illustrative case focuses on a different example of integration that involved drawing together specialists from the same profession but based in different organisations and locations into a single integrated provider organisation. Specifically, this case focuses on the experiences of one STP project team that was established to develop and test the integration of pharmacy services that were previously distributed (and poorly co-ordinated) across multiple hospital and community settings. This example of integration resembles a form of ‘horizontal’ integration in which multiple similar functions or specialists are brought together as a regional-level service. This was part of a national scheme to integrate NHS pharmacy services and medicines optimisation,156 with the aim of ensuring that patients get the most benefit from their medicines, especially for people with complex conditions requiring multiple medicines, while also controlling expenditure on medicines and the additional costs associated with poor adherence and risk. In practical terms, the newly integrated services involved establishing a single pharmacy leadership team for medicines optimisation across the STP region and integrating pharmacy expertise in local services to support, for example, antibiotic stewardship, patient adherence and prescribing practice.

A challenge faced by this integration project was how to create a shared understanding of the value and benefits of local-level service integration, especially when local stakeholders might prefer or benefit from customary models of service delivery or have concerns about the ulterior motives for change. Such tensions were exacerbated by a history of service fragmentation, manifest in both different service delivery models and the corresponding allocation and control of resources. For example, pharmacists in hospital and community settings were accustomed to different work routines, information systems and levels of interprofessional working. One significant area of tension was with the relative financial burden of medicines management. It was reported that the use of block contracts to fund pharmacy services in the acute hospital setting enabled the discounting of medicines for hospital patients, but once a patient moved to a community setting such discounting did not apply and the financial burden of medicines management had to be covered in the budgets of community hospitals and primary care:

. . . supposed to be working together, but there will still be the financial directors of organisations that will want to maintain their books and balance the books. So there is still that financial tension which has an impact, as well as workload issues that get passed across. So that integrating primary, secondary the politics is to do with finance, their contracts, workload, and negotiating with drug pharma[ceutical] companies.

GP lead

For this reason, the project team had to devise a new funding model that would share the risk and benefits across multiple organisations to deliver more integrated medicines management. For service leaders, this key first step made possible subsequent changes by offering a sense of fairness and enabling more collaborative working:

So having the funding which was exactly what it was designed to do was to give them the head space to think about what they needed to do and coming together as a group and really working.

Community pharmacist

There were further tensions around the allocation of distributed leadership roles within a new integrated pharmacy service, especially whether hospital or community pharmacists would have a greater influence on decision-making. For example, individual NHS trusts were anxious about losing a portion of their pharmacists’ time to the new system-wide model of working, resulting in a need to backfill their time in the hospital. Moreover, chief pharmacists from individual trusts were critical of being made subordinate to peers who have acquired leadership roles within the STP; for this reason, ensuring some elevated or senior status for the hospital pharmacist community was seen as necessary as a kind of recognition and compensation for new ways of working:

I think that having the new chief pharmacist in the hospitals has really helped. There was a . . . there was a sort of us and them going on before, because the providers were separate from the commissioners. There was a wall between them and that was the way it was all set up but now of course it is all integration.

Project lead

An additional complication was the persistence of technical, functional and cultural differences in the working practices of hospital and community pharmacists, especially the character and depth of the relationships that they developed with other clinical groups and understanding the logistics of working and different population needs. The project team, therefore, needed to secure the active involvement of pharmacy leaders and pharmacists working across the hospital and community sectors, and also the support of the organisations within which they worked:

At this point I re-established informally the leaders from all the partner organisations . . . We starting meeting, and we just started discussing what bits of work would be beneficial from the pharmacy perspective to . . . work on collaboratively . . . And so we’ve built up the relationships again, and we did actually agree on some key areas that would be beneficial to work on collaboratively.

Project lead

The early stages of project activity demonstrated the prevailing tensions within the landscape. This was evident through the marked lack of engagement of certain hospital providers and when representatives did attend project meetings it was observed that interactions among pharmacists and the STP lead were often ‘awkward’, with pharmacists often voicing concerns about their changed role. Perhaps more significant were the breakdowns in relations manifest in the silences and refusal to give consent to proposals. In other words, political action can involve inaction and withdrawal as much as active opposition.

In seeking to reconcile these tensions, the project leaders reflected on the range of system representatives involved in project planning and also the wider engagement work. In particular, it was decided to involve additional pharmacy leaders who could speak to the different roles and responsibilities of pharmacists across the wider care system, not just hospital and community services. It was also thought to be important to utilise existing connections to invite more independent (non-pharmacy) perspectives from across the care system to help to contextualise the pharmacy viewpoint and help stakeholders to see the bigger picture. On the one hand, participants talked of putting the patient perspective at the centre of the conversations and guiding the strategy, and on the other hand they also talked of the absence of medical involvement that was seen by some as dominating conversations:

. . . you can talk about how, well if we can work better together as a group and you may lose a little bit and we may lose a little bit. We work together and in an altruistic way it’s better for patients, it might be more efficient, some losers, some gainers, that kind of approach, give and take approach, and our negotiations can occur in that fashion.

GP leader

Through changing the range of people involved in project planning and implementation, the project team were able to develop a more fine-tuned understanding of the common and diverse pressures across the system and, importantly, were able to foster corresponding shared understanding among regional stakeholders. Building on this new insight, project leaders set about devising a revised communication strategy that incorporated the various concerns and aspirations into a clear and consistent vision around which there was a large degree of consensus. In particular, service leaders emphasised the big picture and greater good, framing strategies that meant an acceptance of losing some aspects of pharmacy work for the greater benefit of the system and patients.

That said, some degree of opposition remained, especially in the allocation of new system-wide leadership roles for pharmacists and how changes would negatively affect the day-to-day work of some hospital and community pharmacists. The main responses to these concerns were, in the first instance, to identify and promote ‘win–win’ situations that demonstrated the overall benefits to individual service organisations even when they might not appear of particular benefit. For example, pharmacy leaders emphasised how the proposed initiative would have collective benefits for the profession, especially for raising its profile in the division of labour, offering greater autonomy to pharmacists and ensuring that it played a more direct and ongoing role in new models of working. Another strategy was to develop forms of compensation to placate vocal resistance to change. For example, a number of pharmacists expressed concerns about the allocation of new leadership roles and responsibilities, but seemed to be appeased by being offered a new peer-pharmacist role to help coach and support other pharmacists (Box 7).

Illustration 8: the politics of sustainability in workforce development

Case eight focuses on the political challenges of sustaining and extending transformation activities beyond the initial project work. It focuses on the experience of one STP project team leading a portfolio of organisational and workforce development activities across the region. This initially had a very specific remit to facilitate joint health-care and social care apprenticeships to address skills shortages in these areas and then evolved to include workforce development activities to support integrated and interprofessional working across the system. Over a 2-year period, the project team developed a series of targeted and system-wide workforce initiatives, but often with variable levels of engagement with regional stakeholders in health-care and social care sectors. Furthermore, financial support for this project team was always time limited or project limited and stemmed from multiple sources, including STP funds and financial support from individual NHS organisations or external bodies, such as Health Education England. A major challenge for the project team, therefore, has been to develop longer-term change initiatives and secure their position within the system landscape, especially given that they were required to seek refinancing on an annual basis or to secure external funding:

The real problem is the lack of longer-term funding so we can put together a more substantial programme of workforce development and offer people a kind of pathway for career progress.

Field note: workforce lead

The case brings to light the challenges of a new, small team building sustainable collaborations with larger, more hierarchical stakeholder organisations. The experiences of the project team bring to light the key issues of stakeholder engagement and funding as having an impact on the sustainability of change. Team members reflected that their work was not always valued by stakeholder organisations, and even when senior leaders talked about the importance of a ‘systems approach’ to workforce development, too often middle managers within individual organisations would continue to develop internal activities rather than engage in the STP projects. Reflecting on these challenges, team members described variable levels of support. Some small organisations were more positively engaged in and supportive of the work, whereas other, larger, NHS trusts would be less engaged and act more unilaterally in disengaging with the project team and using their own financial resources to develop internal and bespoke programmes. There were added complications about where resources were managed and who was accountable for project team activities, which meant that some stakeholders saw project work as being aligned with certain sectors rather than others. Even when funding was secured from an external agency, it often led to relatively short-term project-focused engagement rather than more sustained collaboration. One team member suggested that individual organisations were fearful of the system-wide approach being taken by the project team because they saw it as threatening their own roles and responsibilities. Other organisations did not feel the need to collaborate and were happy with their own ‘in-house’ activities. The project lead reflected on that need to constantly justify what they do and to ‘sell themselves’:

The [STP] board is very supportive and seems to understand how a workforce programme could go alongside new service models or the shift of services to the community, but the workforce leads in the individual trusts can only see what their organisation needs and so they allocate the budgets in ways that support them.

Project lead

In seeking to establish a more sustainable basis for their activities, the team showed clear signs of collective self-reflection by appraising their success and struggles and considering their image and reputation in the wider system (i.e. why did they keep needing to justify their worth). They also considered whether or not they had the appropriate people and groups involved in the wider project activities, especially on standing committees. They also identified key people in a small number of prominent organisations as ‘blocking’ their progress through not engaging in system-wide development programmes and communicating opportunities within their organisations:

We needed the time to reflect as a team and share our experiences of trying to work in the system and recognise what does and what doesn’t seem to.

Field note: workforce team member

For this reason, a dual strategy was developed to better engage more senior system leaders and to better demonstrate their contribution to the overarching STP agenda by building on projects that had been successful. This involved working with more supportive organisations to evidence their success stories to ‘convince the unconvinced’. They also described working more closely with influential individuals who could promote their work and widening their communication activities to reach those leaders who might not hear about their work because of the negative role played by middle managers and HR leads within individual organisations:

We have tried to build the evidence across a number of levels. So showing how what we do can contribute to how services work in their own right and how they can work better together. There are some obvious indicators around staff retention but the key is to show the clinical improvements and potential for costs savings.

Project lead

As part of their new engagement strategy, the project team described working within the less-engaged partner organisations to encourage them to determine the system-wide priorities that might foster their future involvement, but which could also be used as a way to hold them to account for future funding obligations (Box 8).

Thematic cross-case analysis

Cross-case analysis supports the identification of a number of common themes and issues that characterise and contextualise how political skills, strategies and actions are used in the formulation and implementation of major system change. These represent significant empirical and conceptual contributions to the existing literature on organisational politics and political skill as found in the wider social science and health services research literature.

Experiential learning

Experiential learning involves acquiring and developing skills through direct involvement in real-world or situated activities in which people ‘learn through doing’. 157,158 Skills are moulded through ‘hands-on’ experience and leaders gradually develop the competencies or ‘know-how’ to read situations, understand stakeholders and learn resilience. 43,159 The experiential development of political skill can be haphazard and costly and mistakes can be damaging, with Hartley et al. 73 showing that many skills and qualities are acquired and honed through ‘trial and error’. 73 Others72,159 suggest that people can be more proactive in their learning in the form of either self-reflection or self-monitoring. The concept of experiential learning has traditionally been associated with reflective learning through practical activity;160,161 however, within the political skill literature, it aligns more with ideas of cognitive or ‘personal learning’, for which knowledge is seen as an entity and the person as ‘a personal container’ of knowledge. 72,159

Mentoring and coaching

Mentoring and coaching feature prominently in the literature. 72 Mentors can support mentees to ‘reflect on practice’ and develop new ways of behaving. 72,131 Research suggests that mentors can provide timely feedback, read situations and understand prevailing power structures. 131 In general, mentoring is described to lead to increased political skill and job performance and the ability to appear sincere and influence others. 159 Mentoring programmes that include Ferris et al. ’s53 concept of political skill have also helped nurses to reach more senior positions. 131

Mentoring is a two-way exchange that is often initiated by the mentee;114 this means that some form of political skill is needed to initiate a mentoring relationship. 162 The workplace learning literature also suggests that mentees can benefit from multiple dispersed mentors to address different aspects or challenges of their workplace. 163

Mentoring can be particularly useful for female leaders. Mainiero’s153 study on female managers found that women need political skills to ‘break the glass ceiling’153 and to overcome the deep-rooted cultures and norms that can stymie career progression. Although women do benefit from mentors, they often lack them owing to bias in the workplace, and men who mentor women can be put off by the reaction of other male colleagues. 162

There is less material in the literature about executive coaching. Generally, coaching is seen as only one approach to skill development and tends to focus on psychological and behavioural enhancements. 71,159,164 Perrewé and Nelson162 note that executive coaching increases ‘understanding and psychological awareness’162 and builds important relationships. 162 In the grey literature, executive coaching programmes directly and indirectly engage with the concept of political skill through components such as ‘developing interpersonal relationships’. 165 The NHS Leadership Academy offers executive coaching with the aim of developing the trainee’s understanding of work teams. 166 Barriers to coaching are often highlighted, particularly expense and exclusivity. 159

Formal training programmes

There is evidence that formal training can support increased awareness of organisational politics and the development of political skill. 167,168 Furthermore, training programmes can supplement workplace learning and mentoring158 and are considered useful for aspiring leaders. 169 Training sessions legitimise a way to talk about organisational politics and encourage dialogue about ‘thorny issues’. 170 Group-based training sessions are seen as especially important for resolving real-life problems, with a focus on developing shared strategies for change. 170 An important caveat for formal development is that psychological safety is needed and some programmes have failed because of a lack of attention in this regard. 159 In terms of the format of training sessions, some authors recommend a blend of learning methods. For example, Ferris et al. 159 suggest bringing organisational politics to life using drama-based approaches. However, formal training programmes are often competency based (demonstrating learning of prescribed skills and abilities) and do not always show how the skills should be applied in a dynamic context. 171 As previously noted, formal provision is especially important for women, one reason being that they are more likely to view organisational politics negatively. 162

Summary

The evidence on the acquisition of political skills is sparse and diverse. Many studies continue to see some people as ‘naturally’ gifted or capable of engaging in political behaviour,43 whereas others suggest that such skills can be learnt and honed through experience, mentoring and training. Arguably, these two positions can be reconciled by the idea that some people more readily develop political skill because of their innate ‘talent’, whereas for others skill development requires more effort in explicit learning. Although political skill is acknowledged across prominent health-care leadership frameworks, there is little evidence of how it is best acquired or contributes to health-care change. Many of the attributes are poorly specified or are subsumed within other behavioural competencies. Even when there is explicit reference to political skill, there is limited theory on which these qualities are based and there is no explanation about how the concept has been adapted to the NHS context.

Experiential learning

Almost all participants described their growing awareness of organisational politics and their acquisition of political skill as stemming from experiential learning or involvement in specific ‘events’, ‘projects’ or ‘placements’. These experiences provided the basis for learning about the political landscape and the political behaviours of others and, importantly, for reflective understanding of their own attitudes, beliefs and behaviours in relation to others:

So I was the lead director for [the trust’s] division and I remember going into [the] station once and putting across a proposal that I thought was quite sensible and the PTR, the paramedic team leader, at the coffee break said you’ll never get that through here because this is going on and you need to know the background here and actually it’s something about understanding the politics of that station or that division, so what are those other things that are going on . . .

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Participants’ involvement in these situations varied according to career stage. Early career participants described these situations as novel and significant, often because this was the first time that organisational politics were encountered. For a number of participants, these early career encounters focused on a role model and ‘watching them in action’. These role models tended to be senior or more experienced leaders who provided a template on which to model behaviour at different stages of their careers. As well as ‘positive’ role models, some participants talked about ‘negative’ role models or people whose behaviour they would not want to emulate, such as the politically naive or those who often offended others or made mistakes. By contrast, more senior participants talked of honing their skills through ongoing participation in change projects.

Nearly all participants talked about ‘seminal moments’ that brought organisational politics and political skill to the fore of their attention and provided the impetus for reflection learning and personal development. A number described these moments as not only novel but also personally challenging, emotional or embarrassing. Some saw these situations as exposing their naivety or lack of judgement, which prompted personal development expectations. Many of these seminal events were described as errors of judgement, behavioural mistakes or other forms of faux pas that contravened expected behaviours.

Participants also talked about other significant experiences as enhancing their awareness of organisational politics. In particular, working in or across multiple organisational settings was seen as beneficial for highlighting subtle differences in informal organisational politics that might otherwise be taken for granted. Certain types of care settings were described as especially ‘rich’ in experiential learning because of their underlying political character, such as working in specialist hospitals. Those who had worked in both ‘health’ and ‘social care’ settings talked of their enhanced understanding of the different financial and national political pressures, which, in turn, made some more able to work across these boundaries:

Being in different sectors, that in itself, opens up your mind to different ways of working and obviously the people within those sectors, have got different experiences and the training and development opportunities that I have been on, formally.

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A relatively small number of participants talked about learning through exposure to formal (big P) politics and political processes. A number of participants had previously worked, for example, as civil servants in the central or local government, some participants had undertaken leadership placements with central government agencies and other participants had been seconded as specialist advisors to government departments, policy committees and regulatory bodies. These participants saw such exposure as helping to develop their skills for when they returned to their usual leadership or clinical roles within the health and care sectors. Further sources of experiential learning came from participants’ past experience of working in non-health-care or public service sectors, through either the third sector or private industry. Those with experience in industry mentioned with some surprise that staff within the NHS often appeared unaware or naive about the influence of office or organisational politics, despite it being such an obvious feature of the health and care sector.

Mentoring and coaching

As above, many participants talked of role models helping them to understand and navigate organisational politics. Some of these mentoring relationships were relatively formal, established as part of a training initiative or induction programme, whereas others were more informal, dynamic or issue based, being formed through pre-existing connections or when a line manager had mediated a mentoring relationship to assist with a given issue or career stage, for example a promotion application:

I’ve been really fortunate with mentors, unofficial mentors, official mentors, role models, [name] was one of them. And some other key people that I’ve developed relationships with that have helped me and people that I’ve looked up to and seen how they work and tried to emulate that myself.

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Of interest here, participants described the benefits of mentors in three overlapping ways. The first was orientating or understanding the political landscape. This included, for example, explaining the power dynamics in a given service or helping to anticipate political issues. The second was developing connections within the organisation. This involved a mentor making a preliminary introduction on behalf of the individual or endorsing their involvement in a given activity. The third was creating a ‘safe space’ for personal reflection and to offer ‘constructive criticism’. In most cases, these interactions were seen as developmental, allowing for exploration and reflection on events and possible actions. This was especially the case for participants who felt that they had made a political ‘faux pas’ or had met significant resistance to a piece of their work. These interactions tended to be described as informal and confidential, with a view of helping the participant to reflect on their behaviour and think of alternative strategies.

Although less common, a number of participants also talked of receiving ‘coaching’. There seemed to be two different approaches to coaching. The first might be termed ‘executive coaching’ and was described by a relatively small group of senior-level participants, for example chief executives, and was arranged on a private or ad hoc basis to provide confidential and independent guidance around key leadership issues. The second might be termed ‘placement coaching’ and was provided to participants as part of their formal leadership development. In some ways, participants talked of their coaches in similar ways to mentors, but with a focus on planning and rehearsing different scenarios in advance of taking action. In most cases, coaching seemed narrower in focus than mentoring, being focused more on self-reflective personal development:

Coaching can be very good. And to be fair, I’ve personally had a more I think, use out of coaching, and I know certain colleagues have certainly found coaching really useful. And in a way, all the coaches largely actually only self-reflect back individuals, back their style and their approach, and how they work, but sometimes that’s quite useful.

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Formal training

The majority of participants had undertaken some kind of formal leadership or management training over the course of their career. Many participants had completed, or were still enrolled in, national management training programmes, others had completed specialist postgraduate programmes in clinical leadership, a few completed a Master’s degree in business/administration, and many had attended short courses on leadership development. Despite the widespread experience of formal training, it was striking that only a small number of participants (< 15) talked of receiving formal training in the areas of organisational politics and political skill.

A small number of participants talked positively about their experience of an interactive workshop on organisational politics that was provided as part of their enrolment on a national leadership programme. This was facilitated by an academic researcher and involved a mixture of structured teaching and group work in which participants applied concepts related to organisational politics to their work experiences. Although positively received, they also questioned whether or not, at their career stage, they had sufficient first-hand experience to fully appreciate these issues or to relate concepts to their work context:

[We] had some kind of training in how to frame problems, change, help develop people’s thinking in certain ways . . . it was really new to me and it made so much sense and it was, it was like a relief that somebody was naming power and politics. I was doing it before, but I was doing it unconsciously and I was doing it based on my own personality and wit and my nature, but once I could put something, I could see that people had been talking about this and the normalisation I think is really important. It takes so much guilt away.

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A small number of participants talked about attending bespoke training on ‘the politics of organisational change’ (or with similar themes) that had been designed by external ‘organisational development’ consultants to address their employing organisation’s priorities for change. Such workshops introduced common ideas related to organisational politics and encouraged participants to apply these to their own work. Some of the memorable or prominent ideas that were described included, for example, Baddley and James’s167 characterisation of political skill in terms of animal metaphors. Such training was experienced positively because the broader theme of organisational politics continued to be under-recognised and underdeveloped within more established learning curricula, for example when political issues were subsumed within such themes as culture change or change management. In other words, training recognised the importance of the issue and gave permission for participants to talk about organisational politics, which was especially important for people working on a shared change project:

. . . was really powerful is that we have 18 people as a cohort and you get to discuss politics and power openly, you can discuss the use of things and gives you the courage to go and test that.

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Overall, formal learning programmes did provide participants with an important opportunity for reflection and learning about organisational politics outside the ‘classroom’. A number of participants talked about their involvement in ‘action-learning’ sets, in which they could bring ‘live’ issues to their learning group for structured and facilitated deconstruction, reflection and action-planning. In addition, participants talked of the benefits of sharing experiences with other learners in and around structured learning activities in the form of peer support.

Summary

Study participants saw merit in formal training activities to structure or guide their learning, but also the importance of experiential learning around real-world challenges to focus their learning. These activities could be supported by aligning mentorship and peer networks with formal training, that is when ‘classroom’ learning is supplemented with additional mentoring.

Participants’ recommendations for formal training suggested that the topic of organisational politics could be introduced early within foundational professional education, that is during undergraduate clinical training, and especially as people start to develop a management or leadership career pathway. It was further suggested that formal learning could be graduated, moving from ‘context-free’ core ideas to more ‘context-specific’ practical strategies to reflect the likely challenges faced by leaders at different career stages. At later career stages, more bespoke and tailored training was preferred in the form of organisational or professional development, with action-learning that was aligned more directly with the real-world challenges to help to build consensus on issues and demands faced by leaders. Such structured learning can be complemented with in-service mentoring, coaching and peer learning. For study participants, the most preferred approach was for a trusted and typically more experienced person to take the individual ‘under their wing’, especially around specific operational or strategic activities.

Understanding change as a journey

This introductory section or activity aims to encourage participants (who share a common change agenda) to think about their change initiative as a process or journey and to invite team members to reflect on the potential political challenges or controversies faced in this journey. This activity was adapted from the NIHR Guide to Implementing Change. 179 This activity is suitable only for groups or project teams working on a shared change project and is not feasible for the ‘open’ workshop given the diversity of change issues, although more general group discussion about change processes can be facilitated in ‘open’ workshops.

Based on feedback from each workshop’s project team leaders (as part of the co-design process), participants were asked to complete ‘pre work’ in the form of developing or sharing a ‘plan on a page’ or similar diagram to summarise their change project, thereby reducing the length of the workshop. In the workshop itself, a project representative then delivered a brief overview of the project, with reference to the ‘plan on a page’, followed by group reflection and discussion on the political controversies. In practice, group discussion was facilitated through the ‘chat’ function in Zoom, but this could also be facilitated through other in-person activities. When participants identified multiple controversies, further discussion was facilitated to identify the ‘key’ issues that were complicating change, again encouraging use of the ‘chat’ function. It would also be possible to close this activity with a deliberated ‘voting exercise’, whereby the participants select the most pressing (urgent) and significant (important) issues that will then become the focus of subsequent group activities.

Participants’ feedback indicated that they generally welcomed the opportunity to discuss with their co-workers the common and divergent expectations for their shared change project. In particular, it was described as surfacing differences within the groups that had hitherto been unnoticed, or an opportunity to question the ‘official’ narrative of change. However, it was also reported that the success of this activity was dependent on the skills of independent facilitation and the willingness of the designated team leaders to engage with divergent views.

Understanding the landscape

The next section of the workshop invited participants to further analyse their political landscape using Jarrett’s180 conceptual matrix of the four types of organisational politics. This matrix characterises organisational environments according to their ‘levels of political activity’ (individual/organisational) and ‘sources of power’ (informal/formal), resulting in four ideal-type settings (weeds, woods, high ground and rocks). 180 Applying this matrix to the health sector, the facilitators used relevant examples drawn from the earlier WPs and emphasised that the political landscape of the health and care sector is highly dynamic across both time and space, especially in the context of system change.

In all workshops, this activity was facilitated as an open plenary discussion. For the workshops with STP project teams, participants were encouraged to reflect on the features of their political landscape that would have an impact on their change processes. For the ‘open’ workshop, participants were invited to reflect on the relevance of these ideas to their individual work contexts and to discuss the common and divergent issues, thereby sharing experiences across participants. For the Healthwatch workshop, the decision was made not to undertake this activity because feedback from the pre-workshop co-design meetings indicated that it was potentially not relevant to public and community groups and possibly too technical or jargonistic.

Reflecting on the use of this tool, some participants struggled with applying the matrix to their particular environment, primarily because it was felt that the health sector could not be defined as one type of landscape (of four). This was addressed in the workshops by encouraging participants to discuss what types or forms of political activity predominated at different times and places, and to recognise the connections between different political environments, for example how decisions in health care impact on decisions in social care. Further feedback suggested, however, that the ideas raised by the use of the Jarrett matrix180 could have been discussed without the use of the four ideal types or categories. The main recommendation was that group discussion could deepen appreciation of the issues, but this required facilitation with developed understanding of the health and social care context to reduce the constraints of the matrix typology.

Understanding stakeholders

This section of the workshops invited workshop participants to identify and appraise the stakeholders relevant to their change agenda. This activity was developed through adapting relatively commonplace stakeholder analysis frameworks,150 as well as more specialist tools aimed at characterising stakeholder types as ‘political animals’167 and also tools to help identify stakeholders’ underlying interests and agendas in terms of the ‘what’s in it for them’ framework. 176

Feedback from the pre-workshop meetings indicated that the two STP project teams had already completed basic stakeholder analysis and they would prefer to revisit this as part of their ‘pre work’, thereby affording more time in the workshops for in-depth stakeholder analysis. By contrast, pre-workshop co-design activities with the Healthwatch organisation indicated that they would prefer to dedicate more time to all aspects of the stakeholder analysis and the ways that different stakeholders could be influenced. In all but one workshop, participants were allocated into ‘breakout groups’ to work through the resources, with the support of a facilitator, leading to the identification and analysis of the key stakeholders. The findings were then shared in plenary discussion to surface common and divergent views.

For the ‘open’ workshop, this session was introduced with a general discussion of the ‘political animal’ concepts, and participants were then invited to discuss in open plenary the actions or responses that such stakeholders might be expected to take with regard to a given change project. For this reason, the workshop surfaced breadth of understanding of the different stakeholders, but less depth than the workshops with discrete project teams.

Feedback indicated that the stakeholder activities were positively received by the project team workshops. They seemed to provide focused and in-depth analysis of key people or groups, especially their particular interests and agendas, from which to devise relevant strategies to manage these stakeholders. Participants of the ‘open’ workshop also seemed to welcome the ideas but reflected that it was something that they would carry out after the event in subsequent project work, because there was limited scope in the workshop to carry out the depth of analysis. A key finding from this activity was the importance of expert facilitation to explain and support the use of the frameworks and tools for stakeholder analysis. In addition, post-workshop feedback suggested that it would be useful to simplify the activity and reduce the reporting back, thereby giving people more time for discussion, but it was also felt to be important not to oversimplify the process.

Understanding and using political skills, strategies and actions

This activity was informed, in part, by the political skills inventory (PSI) developed by Ferris et al. ,178 with the intention that it could be used to foster individual and group critical reflection about the acquisition and use of political skill. In addition, the workshop made use of empirical findings from the HeLPA (Healthcare Leaders’ use of Political Acuteness) study to offer real-world case examples of how political skills, strategies and actions can be used to mediate the local political landscape as a prompt for group reflection and forward planning.

One prominent developmental tool that was identified as part of the scoping review was the PSI developed by Ferris et al. 178 This is a self-completion survey to appraise an individual’s political skill, which could be used as part of a self-reflective exercise. The PSI was reviewed with the expert workshops (see Co-design workshops to test and appraise learning resources) and also with workshop participants as part of the pre-workshop co-design activities. Although the expert panel was broadly supportive of this tool, workshop participants suggested that it was too similar to an academic personality survey and that they were unsure if it would contribute to group learning. It was also recommended that the survey should be distributed and returned in advance of the workshop, with anonymised group feedback offered to foster this group reflection. Despite following this recommendation, it was found that a very small percentage of workshop participants (< 20%) completed and returned the survey, which rendered group discussion unfeasible. For this reason, the PSI was not used directly in the workshops.

Instead, this section of the workshops involved facilitating a discussion among participants about the key strategies and activities that could be used to manage the interests and agendas of different stakeholders (who had been identified and analysed in the previous activity). This ensured a degree of continuity between earlier sections of the workshop and helped participants to build up a more developed understanding of ‘political strategies in context’. For example, workshop discussion was purposefully directed towards addressing the outcomes of the ‘what’s in it for them’ activity, in terms of targeted strategies, negotiation tactics and interpersonal skills with different stakeholders. Importantly, this section of the workshops was informed more directly by the study findings from preceding WPs, including a review of the reported (WP2) and observed (WP3) ‘political skills, strategies and actions’ of service leaders. These findings were then used to prompt discussion and forward planning by workshop participants. This facilitated section was concluded by inviting participants to develop an ‘action plan’, drawing on the materials in the workbook. This section of the workshop was difficult to address in the ‘open’ workshop because of the diverse change issues being discussed by participants.

Feedback from this activity was mixed. Participants broadly described it as the most novel and forward-looking stage of the workshop, especially because it was directed towards formulating strategies to manage organisational politics. However, participants were apprehensive about completing the PSI in advance of the workshop (see Co-design workshops to test and appraise learning resources) and found the application of study findings to specific change contexts to be challenging. The two STP project teams requested a follow-up workshop to focus explicitly on the strategies for dealing with different stakeholders and managing organisational politics. Further feedback suggested that the study findings could have been used to inform a ‘scenario-planning’ or ‘foresight’ exercise in which different tactics were discussed in terms of the anticipated outcomes. Overall, the feedback from participants was that the workshops ended ‘just as the difficult issues’ were being addressed, suggesting a rebalancing of the content with greater emphasis on the action plans, rather than landscape analysis, together with greater use of pre-work via the workbook to inform workshop discussion.

Summary

The co-design workshop, together with preceding activities, informed the development of a package of learning resources and activities and a workbook, together with two slide-decks, one for team development (see Report Supplementary Material 2) and one for third-sector organisations (see Report Supplementary Material 3), with an accompanying facilitator’s guide (see Report Supplementary Material 4).

A significant finding from the co-design workshops was that the package of resources and activities was much better suited to the developmental needs of project teams working on specific change projects, rather than individuals enrolled on or participating in an ‘open’ workshop. Feedback showed, for example, that project teams were able to directly apply the ideas and learning activities to a real-world, practical issue; moreover, this issue was also shared by the group, providing a basis for team-based action-learning. This further reinforced the idea that the development of political skills, strategies and actions is perhaps best targeted at groups, rather than individuals, in which complementary capabilities are distributed and shared among team members. It also demonstrates the importance of understanding and addressing organisational politics as highly context-specific phenomena, involving particular political landscapes and protagonists, further suggesting the relevance of action-learning approaches rather than more abstract or generic learning.

Objective 1

Objective 1 was to identify key theories and frameworks of political astuteness within the social science literature and apply these to recent evidence of health system change to understand how service leaders can constructively create a ‘receptive context’ for change.

Chapter 3 reports the findings of two systematic narrative reviews. The first reviewed the wider social science literature on the concept of political skill and the second reviewed the health services research literature on the application of these concepts to the study of health services change. The first review shows that a number of key frameworks and theories of political skill and astuteness have dominated contemporary organisational and management research. In particular, the concept of political skill developed by Ferris et al. 53 was identified as the most prominent approach to describing and explaining how leaders and other change agents can influence others to realise their personal or organisational objectives. This comprises four dimensions: social astuteness, interpersonal influence, networking ability and apparent sincerity. The first review also identified the concept of ‘political astuteness’ as an alternative approach to studying how people seek to understand and mediate competing interests when seeking to realise certain goals. 54

The second review applied the findings of the first review to the health services research literature, showing that concepts, such as political acuity, astuteness and skill, have a relatively long history, especially in the area of nursing research. Although such terms have often been used in a relatively ‘loose’ or general way, in recent years the concept of political skill drawn from Ferris et al. 53 has become more common, leading to a more ‘tight’ or specific understanding. These have been applied primarily with regard to the nursing profession’s involvement in service change,102 but also with regard to other professional and managerial groups.

The reviews elaborate a critique of the existing literature, especially the Ferris et al. 53 model, which is interpreted as emphasising personal skills and behavioural capabilities43 while potentially downplaying the relational and social context of people engaging in political action. 169 The reviews note important distinctions between a person’s underlying skills or capabilities, the application of these skills in the form of behaviours and actions, the idea that other people will also have such skills and engage in corresponding behaviours, and that such interactions take place within a given context. Taken together, these broaden the focus beyond skills to including actions and interactions and context, thereby calling for closer attention to the interactive and relational dynamics of political action, rather than individualised political skills. By taking an inclusive approach, the narrative review suggests that ‘political action’ is operationalised along a number of interconnected dimensions, including personal performance, contextual understanding, interpersonal influence, stakeholder engagement, networking, organisational change and policy influence. In many ways, this mirrors many of the features set out by the likes of Ferris et al. 53 and Manzie and Hartley,113 but it also indicates other aspects, especially policy influence. Moreover, the review provided the basis for elaborating the linkages between these dimensions as the basis for a heuristic framework to inform subsequent empirical research (see Figure 4).

Objective 2

Objective 2 was to understand the perceptions, experiences and reported practices of service leaders, and other change agents, about their acquisition and use of political astuteness in the implementation of health system change, taking into account differences in professional background, age, gender, ethnicity, geopolitical context and change context.

Chapter 4 reports the findings of the narrative interview study that investigated how health and care leaders perceive, experience and talk about their acquisition and use of political skill in the implementation of health system change. This was informed by the preceding literature reviews and focused on the use of political skill in managing the ‘politics of change’. The study found that participants talked about ‘organisational politics’ and political behaviours (and skills) in a number of common ways. The narrative interviews showed that people tend to think and talk about organisational politics with reference to a wider ‘political landscape’ in terms of historical precedents and prevailing relations of power, within which they experience particular ‘controversies’ or disagreements. As part of explaining these controversies, leaders focus on the role and positions taken by different stakeholders or ‘protagonists’ who hold different preferences or interests for change, and, in turn, the narratives describe the ‘political skills, strategies and actions’ used by these protagonists when seeking to influence the organisation of care. These political skills, strategies and actions were analysed along five dimensions (see Table 9).

Participants’ narratives broadly reflect the prevailing concepts of political skill and astuteness, but they depart empirically and conceptually in four important ways. First, the findings problematise the relatively narrow and individualised view of political skill, revealing instead a more complex and contingent understanding of organisational politics that involves complex patterns of action, interaction and counteraction. The findings suggest that it is useful to see organisational politics as involving interlocking constellations of political action in which multiple actors are seeking to influence one another. Second, the findings demonstrate the importance of a person’s social position in shaping their inclination, opportunities and approach to political action. 152 In particular, career experience and professional background were significant factors conditioning political action. Third, the findings show the importance of understanding political skill and action as a group or collective activity, rather than individual, whereby multiple people work together in complementary ways and with complementary skills to influence the organisation of care. Finally, the study offers insight into the interests and agendas that motivate political action. Within the mainstream literature, political skill is motivated by the desire to realise relatively narrow personal or organisational interests,43 yet study participants’ participation saw organisational politics as framed in terms of improving patient care or public health, in addition to deeper concerns about the allocation of roles and responsibilities. 181

Participants’ narratives also suggest that political action varies at different stages of the change process. Although there was no clear formula of skills to be used at a given time or with a given group, it was possible to identify more common sets of action at different stages of the change process (see Figure 7). These provided the foundations of subsequent in-depth empirical case research. The findings of acquisition and training were reported in Chapter 6 and are addressed further below.

Objective 3

Objective 3 was to understand how recent recipients of NHS leadership programmes think about, have acquired and make use of political astuteness to inform the development of new training resources.

As part of the narrative interview study, all participants, including recent recipients of leadership development programmes, were asked to reflect on the acquisition and development of their political skill. For the recipients of training, the questions focused on the perceived contributions of current training programmes. The study identified three prominent methods of acquiring and developing political skill and related leadership qualities, comprising experiential learning, mentoring and coaching, and formal training. In different ways, these each contribute to the development and refinement of political skills, strategies and actions. Experiential learning was by far the most prominent method of skill development, especially through participating in difficult change initiatives, learning from role models and, importantly, learning from mistakes. Mentoring and coaching were also seen as important, especially as supporting reflection on experienced events and situations and forward planning, and also for helping to connect more formal or classroom learning with the real world of health services change. Although mentors and role models were common to many participants, coaching seemed to be more common to more experienced and senior participants. Formal training activities had a mixed reception. Many described how leadership development could neglect issues of organisational politics or subsumed these within broader aspects of strategic change. When people had experienced specialist or dedicated training on organisational politics and political skill, it was seen as important for this to be grounded in real-world events, not abstract theory, and to be able to take learning back to the shopfloor. The main learning from the interviews was that action-based learning with expert facilitation and mentoring was the preferred method of acquiring and developing political skill.

Objective 4

Objective 4 was to revise existing theoretical models of political skill and astuteness with reference to the wider social, cultural and relational context of health system change from which to develop new theoretical propositions.

The predominant conceptualisation of political skill, both in the wider social science literature and in the health services research literature, is associated with the work of Ferris et al. ,53 and is largely informed by work or organisational psychology. Based on the findings of the literature reviews and the interview study, a number of additional lines of enquiry and conceptual analysis were identified as having potential for expanding this predominant approach and providing the basis for subsequent empirical research.

The first line of development is that, in practice, organisational politics involves multiple people engaging in interconnected and parallel lines of activity that go beyond the idea of individual skills, and focuses instead on the interactive order of organisational politics. To expand this point, people have varying types and degrees of skill in the form of personal capabilities to do something, but these skills come into operation only in highly specific interactive contexts. This involves the formulation and enactment of particular context-specific strategies that align available skills with the given contextual challenge, often in the form of other actors or groups who are themselves entering into an interactive exchange with certain capabilities and skills. 59 For this reason, these skills and strategies come into operational and empirical existence through meaningful action and interactive study, in which the interactive feedback or responses from others requires ongoing microlevel adjustments in the strategy and actions of multiple actors. 59,61 As elaborated below, the interactive dimension ultimately defines the character of organisational politics. The study suggests, therefore, that it is important to explore the interplay between skills (capabilities), strategies (plans) and actions (doings) as the basis of participating in or mediating organisational politics. This means that the unit of analysis can be moved from the actor (and their skills) to the relationships and interactions between multiple actors. 61 The interview study showed that people talked about organisational politics as involving constellations of interdependent and interacting actors. The iterative and recursive turn-taking interactions among people define the reality of organisational politics.

The second line of development extends the first by suggesting that political action is rarely an individual behaviour of a given leader of change; rather, political action is a highly co-ordinated and collective activity. In many instances, political action involves multiple people working together as an alliance to counter the influence of other alliances. This clearly resonates with research on social movements10,182 and, more recently, field theory,62 which describe the important contribution of social groups working in co-ordinated ways to challenge, create and defend social institutions. Moreover, the study suggests that by viewing political action as a collective process it becomes possible to understand how political skills and actions are distributed and co-ordinated across different people within a group. Relating these ideas to the leadership literature, it further reinforces the view that organisation and reorganisation of public and health-care services is dependent less on the transformational vision and capabilities of heroic leaders, but more on the distributed and shared practices of leadership by multiple actors. 21 Collective leadership involved co-ordinating across distributed assets and capabilities through an emergent social process,21 which in the case of this study centred on the co-ordinated political capabilities and resources of multiple actors.

The third line more explicitly acknowledges that people do not engage in organisational politics, either individually or as a group, from equal starting positions. Rather, people occupy variable ‘social positions’ relative to one other that reflect different inclinations and opportunities (or dispositions) to engage in political action. 63,152 In particular, relatively powerful or influential people tend to be privileged by the prevailing distribution of resources, rules and relationships, meaning that their willingness and need to engage in organisational politics, as well as their strategies and actions, will be markedly different from those who are less privileged. For example, non-dominant actors might be expected to use strategies and actions that challenge and undermine the position of those in more dominant positions. 26

The final line of enquiry is less theoretical and more substantive in focus. The existing literature tends to deal with politics and political skill within organisation settings. However, contemporary public service reforms, especially in the field of health and social care, increasingly involve implementing change among and within organisations. What becomes further significant about this aspect of interorganisational change is that those leading change often lack the formal authority associated with a given organisational role, and more often need to rely on forms of political skill to enact influence beyond authority. 22 For this reason, more attention is need to ‘system politics’.

Objective 5

Objective 5 was to investigate how political astuteness is used constructively by service leaders to create a ‘receptive context’ for implementing major health system change.

The in-depth case study research with three STPs showed how ‘system politics’ is manifest in the implementation of system change. In the aggregate and comparative analysis of individual cases, the study shows that the stages of implementing change are associated with particular types of political controversy or disagreement operating across the strategic and operational domains. Moreover, it shows how these controversies and, importantly, the resolution of these controversies are associated with certain types and forms of political skill, strategy and action. The study shows how there is little in the way of a formula or prescribed set of skills, strategies or actions for engaging in system politics; rather, it is highly contingency based and iterative. In fact, the case studies showed how precarious and complicated system change can be, with many false starts and failed activities.

With specific reference to the theoretical and empirical gaps outlined above, the research further demonstrates how ‘system politics’ was manifest through highly dynamic and context-specific challenges that required individuals, but more often groups and teams, to make situated assessments and test out various approaches to understanding and influencing their stakeholders. Of particular note, system politics seemed to play out across vertical and horizontal dimensions, simultaneously. The horizontal dimension describes the forms of political interaction observed between individuals, groups or organisations operating at the same level, that is profession–profession or department–department. The vertical dimension describes the forms of political actions observed between, for instance, the ‘strategic’ arena of senior leadership and the ‘operational’ arena of service organisation and delivery. At this level, system politics is typically focused on the ‘top-down’ influence of decision-makers to formulate and implement change (often in concert with formal authority structures); the bottom-up influence of front-line clinicians to inform, shape or contest change; and further the mediating role of middle-level actors to resolve the tensions between the levels.

The composite analysis or synthesis of case findings suggests that certain configurations of skills, strategies and actions were more prominent at certain stages of the change process than others, recognising that these stages often overlapped and involved dynamic feedback and recursive change (see Table 13).

Objective 6

Objective 6 was to work with providers of NHS leadership training, NHS recruitment agencies and PPI groups to co-design recruitment and learning materials that support the acquisition, use and development of political astuteness for existing and future health-care leaders.

The findings of the literature reviews and qualitative studies were deliberated through a series of workshops with the intention of co-designing a package of learning resources and materials. The initial workshops focused on deepening the understanding of the learning needs and opportunities, whereas later workshops reviewed and co-designed ‘candidate’ resources. The findings of the reviews and qualitative research suggested that a relatively structured, even formal, approach to leadership development would be beneficial, but also that this should be directed towards real-world issues and ideally involve action-learning by people and teams working on a shared issue, rather than focusing primarily on theory and prescriptive guidance. The later workshops collaborated with different system change project teams to plan, test and appraise the package of learning resources, leading to feedback and iterative changes. Based on this learning, the study produced (1) a slide deck of structured activities and tools to be used during facilitated workshops, which can be adapted in consultation with teams to suit learning needs; (2) a facilitator guide to explain how the workshops and resources can be planned, adapted and used; and (3) a workbook for use before, during and after the workshop. These resources could also be used by NHS recruitment bodies to support the appraisal of candidates through structured assessment activities.

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This is designed as a general topic/prompt guide for use with health service managers or leaders. The questions are illustrative prompts and the expectation is that they will be adapted to reflect the circumstances and responses of individual participants.