Escolar Documentos
Profissional Documentos
Cultura Documentos
4, 1997
action
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Factor OO
/ of sample
Thorough consultation 69
Talking to people and explaining the changes 56
Teamwork 55
Ensuring the need for change is agreed 51
Ownership of the change 49
The use of demonstration projects 47
Constraints of time 47
Predicting potential barriers to change 47
The avoidance of imposed change 44
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Awareness of timescales 44
Presentation of the change 44
Harnessing committees 42
Constraints of money 36
The personal position of the change leader 35
or model, of the change process in medicine and from it beyond. The professional characteristics of medicine out-
derived a format for semi-structured interviews. The inter- weigh any national cultural variations.
views were focused on particular recent episodes of change The list in Table 1 indicates our interviewees’ preferred
in which the participants had been involved. We tried to style of change and the optimal process of change. The
avoid a discussion of change in the abstract and to avoid a desires of thorough consultation and for people to have
detailed but narrow analysis of a few specific changes. We changes explained to them personally mean that agreed
wanted a broad range of changes and we wanted practical change could be a long process. The desire for wide
For personal use only.
information. The interview format was pilot tested by a ownership of the change and the preference for demon-
representative group. stration projects also imply that slow and steady progress is
We carried out interviews with a sample of 55 doctors, preferred to untested radical changes.
loosely arranged in the five groups listed (below):
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Managing change in a medical context
explaining, listening
(5) Publicize widely Vision, presentation, amending proposals,
corn munication
Agree detailed plans Produce plans
Implement Demonstration projects, have an
implementation strategy, avoid scheming and
bypassing key people
(8) Provide support Overcome difficulties, encourage new
behaviour, expect resistance, deal with
objections
(9)
(10)
Ji plans
Evaluate outcomes
I Accommodate small alterations, compensate
losers
Needs met, benefits realized, modifications
needed, evaluation strategy, problem solved
For personal use only.
model to guide the attempt to introduce induction and menu from which to select the optimal approach for each
counselling systems for pre-registration house officers at particular circumstance.
two district general hospitals. As part of the challenge, we The essence of the model of change is that the bulk of
were to work with the clinical tutor acting as change the effort should be put into the preparation phase; estab-
leader. The two demonstration projects were successful in lishing the need or outlining the opportunity, ensuring
that induction and counselling systems were designed, sufficient power to act, designing the new system with
developed and implemented at both sites. The model consultation and publicity and modifymg the design until it
proved particularly useful as a planning framework that is the best that can be achieved within the constraints of
allowed us to identify at what stage of the change we were time and effort available. If these aspects are properly
operating. In using the model, we were able to make some handled, there will be far fewer difficulties when the im-
small modifications to it which helped to clarify the change plementation phase is reached because everyone involved
process. We also learned how important it is to prepare for will have known all about the project and will have had
change through discussion and negotiation and to avoid their views taken into account in the final design.
premature implementation. Change is not necessarily a smooth linear process and
The model presented in Figure 1 is the refined version. it is quite normal to find oneself moving backwards and
forwards among the various stages or processes. With the
best will in the world and with the best planning, it is still
possible to meet brick walls or large obstacles in your
An action plan chosen path. It is here that a fine judgement is needed to
The remainder of this booklet is dedicated to a thorough determine the next steps.
explanation of the model of medical change. This descrip- The brick wall may be telling you that the project, in its
tion should act as a stimulus to those contemplating or current form, is not viable. In this case you may wish to
involved in change. The description of the model is itself backtrack and find another route forward, avoiding the
an action plan which can be used, whatever stage your wall by modifying your design or seeking new supporters.
change programme has reached. If you have already em- You may wish to undermine the wall, or you may have to
barked on a particular change, it may be wise to take note accept that what you were attempting was too ambitious.
of the stages that you have already completed, in case there We feel that if the processes of consultation, discussion
is something that was overlooked or not handled as well as and refining of ideas has been adequately carried out, then
possible. Whether you are contemplating change or in- there should not be insurmountable obstacles in the cho-
volved in it, the descriptions of the core activities and their sen path.
associated tactical choices and styles provide a substantial If external circumstances change the rules of operation
24 1
R. Gale &'J. Grant
or the basic need for the chosen change, it may be best to and accommodate this factor. At the least, the power
abandon the current initiative and try again later, with a to hinder must be neutralized through discussion and
suitably modified version. compromise.
The next section discusses professional characteristics ( 6 ) Commitment, energy & enthusiasm and motives: These
and styles; these describe the normal medical way of going are personal attributes required of the change lead-
about things, or the overall context in which other actions er(s). Without commitment from the group leading a
must be set. Understanding the context and the opportuni- change, little will happen. Without the application of
ties and limitations it offers is an essential starting point. time and energy to the process, little will happen. If
The following provides the information on what you there are any suspicions concerning hidden motives or
actually have to do to put the model into practice. It does hidden agendas for change on the part of the leader or
so by discussing the core steps and their associated tactics leading group, there will be little constructive progress
and styles. It is the responsibility of the person proposing and much bickering, resentment and subtle undermin-
change to choose the balance of emphasis of the various ing. Commitment and energy are communicable and
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components of the model according to local conditions contagious in that they will be transmitted to others
and circumstances. and have an influence on the success of the venture.
On the other hand, doubts about the motives of
change leaders and worries over their potential per-
Professional characteristics and styles sonal gains have a negative effect on the process and
The context of medicine must be recognized and taken progress of change.
into account if change is to be successful and lasting.
Characteristics and styles which must be considered are as
follows: The core activities and associated tactical choices
and styles
Consultation: Doctors expect to be asked, to be con-
Establish the need or benefit
sulted and not to be told what to do. This is as true on
a national scale as it is locally when dealing with Identify a shared problem, seek solutions, do not sell
colleagues or members of your own team. Consul- them.
For personal use only.
tation makes good sense in that it uncovers a rich seam Lobbying, consultation, conjunction of circumstances.
of ideas and thoughts. Consultation is a signalling
process, it is the first step in change, the first indication For any proposed change, it is vital to establish the need or
that there may be other ways of doing things. benefit. This must be shared by all those upon whom the
Demonstration projects: The scientific basis of medicine change will have an impact. Perception of need or benefit
leads to a reliance on scientific methods in organiza- is fundamental. Change is an uphill struggle, even more so
tion too. Doctors place greater validity on the out- without a widely accepted need.
comes of proper trials, or demonstration projects, than The need or problem may arise from a crisis, poor
they do on personal opinions. In managing change it is exam performance, student unrest, low uptake of post-
important to be aware of this factor and to present graduate training, cuts in funds, for example. It could also
change on a rational basis. This can be through the use arise as a benefit in the form of the desire to effect
of references to the work of others or presentation of substantial improvements in quality or reduce the effort to
reports of similar changes made elsewhere. achieve a particular goal as a result of better methods
Evolution: Gradual change is preferred to radical or becoming available. The need sometimes arises as an op-
gross change. The progress of medicine as a whole portunity brought about by the conjunction of two or more
consists of a series of small advances and improve- circumstances. These opportunities may only exist for a
ments and a similar style of organizational or educa- short time and may not be repeated for many years. An
tional development is desirable. An evolutionary example might be the retirement of a departmental head at
approach allows people time to adjust to the changes the time when resources are available and a new dean has
and to assimilate them. There are, however, times of arrived, or a known future reorganization of local post-
crisis when more radical and rapid change is needed. graduate education arrangements coinciding with available
Ownership: The autonomy of doctors means that they resources and the availability of manpower. The need may
will not generally be enthusiastic about change unless also arise in relation to a directive from above.
they feel they are the owners. Ownership is the percep- The hazard faced by most potential change leaders is to
tion that the changes proposed are your solution to establish the need or benefit for change without putting
your problems. For a change leader, wide ownership forward a particular proposal to meet the need. From the
of the change process presents a possible dilution of standpoint of spreading ownership and gaining commit-
the concept or ambiguity in the direction and control ment from those affected by the change, it is essential to
of the process. Without a spread of ownership, how- separate the need for change from proposed solutions.
ever, there will be little enthusiasm and progress. This is difficult because we often understand the need for
Power to hinder: The autonomy of doctors gives them a change in terms of what we could do to improve matters,
power of veto over many types of change. Doctors are rather than in terms of exactly what the opportunities are
not as interdependent as many professionals in other or what is wrong. Despite the difficulty, it must be done
organizations and face fewer consequences for lack of and the change leader must promote needs, not solutions,
cooperation. Proposers of change need to recognize must explain the opportunity, not his or her pet proposal.
242
Managing change in a medical contexr
of discussion then acts to incorporate their views and to authority or may be natural leaders. Second, power can
trigger their interest and involvement. Even at this early also be gained by spreading ownership of the process to a
stage, it pays to think ahead and to make sure that all larger group of colleagues. In this way a critical mass for
important and influential people who can determine the change can be developed which itself has political power in
outcome of the initiative are involved at the beginning. a local context. At this point, it is worthwhile speculating
People do not like to think they have been consulted as a on the spread of impact of the changes, whatever form they
last resort and much prefer to be informed or consulted take, and making sure that all affected parties are aware
early in the process. The dangers of fuelling the opposition and that none of them has any power of veto.
are much less than the penalties of slighting the home
team. A group of students wanted to introduce more prob-
Sometimes it will be necessary to have a mandate to lem-based learning into their curriculum. They orga-
proceed with a change initiative and it may be necessary to nized this themselves, encouraged teachers to join in
secure agreement from a local or regional committee. It and enlisted their dean. Unfortunately, there was a
may be prudent to lobby the members of that committee to greater power, the examination authority, who had
For personal use only.
ensure their full understanding of the issues. It may also be not been consulted and refused to accept the new
prudent to lobby your colleagues if their support is needed, teaching as valid.
even if there is no need for their formal approval.
In summary, it is important to establish the need or
benefit for change separate from the potential solutions or Another useful strategy to account for lack of personal
developments. Agreement on the need to do something is power is to borrow some power from an important person.
separate from agreement on what to do. This may take the form of agreement to participate in the
project in some limited fashion or agreement to clear lines
of communication to higher authorities, for example. The
Power to act borrowed power is used to raise the status and profile of
the change initiative.
Key people, ownership, harnessing committees, auth-
Committees can be used positively to promote change
ority, borrowed power, politicaVexterna1power, personal
by conferring their authority on individuals or groups.
position, local environment
They can also act negatively if not informed of change
Change is a political process and depends on power. Hav- initiatives early enough.
ing established a need or opportunity for change, it is In summary, power is needed to bring about change.
necessary to look at the sources of power to move the Power can come from personal sources or from position.
change forward and the forces which might hinder it. Power can be borrowed in the form of authority to take
A primary consideration should concern the ability of action or by using the good offices of a powerful person.
the hospital or practice, say, to withstand the rigours of a
change process. There must be a sufficient number of
people with the time, skills and abilities needed for the Design the innovation
degree of change proposed and the local organization must Feasible? Resources, timing, timescale, scale, degree,
be capable of absorbing such a change without terminally involvement, directive/elective, predicting pathways and
destructive consequences. barriers, winners and losers
The organization may have the ability to change, but
the change leader still needs to ensure sufficient power to Consideration of the need or benefit for change and a
carry through the changes. Power can come from posi- review of available power will have helped to put
tional authority or from external and political sources or boundaries around the possible design of a new system.
from charismatic influence over others or from recognized Some other factors are also important.
leadership. Other sources of power arise from being a Is the proposed change feasible? Is its scale or degree
mandated representative of a group, an authority, or of a over-ambitious or too costly and is it within our abilities to
Royal College. Power also resides in enthusiasm and action achieve? Have we access to sufficient material and human
and it is often surprising how much influence motivated resources to implement this proposed change? It is import-
people can have. ant to tackle something that is ambitious and worthwhile
243
R. Gale & J. Grant
and yet remains within the available capacity. It may be puts the maximum effort into reviewing the forces of
wise to tackle a major change as a series of smaller ones. opposition and seeking ways in which to weaken their
The timing of change needs to be addressed. There are effect. This may be achieved by encouraging key individu-
times when organizations suffer from what is termed initia- als to defect or by changing the design of the innovation to
tive overload; they cannot cope with anything else. If there avoid likely opposition or by incorporating opposition
is any flexibility, it would be worth trying to choose a ideas. This review process may show the opposition for a
favourable time for the change. particular design of change to be too powerful to continue.
Most people who have undertaken a major change If the change is thought feasible, it is helpful to put the
agree that they seriously underestimated the time it would positive and negative forces in order of significance and to
take. Major changes are discussed in years and not tackle the strongest opponents first. Some effort needs to
months. The most time-consuming item was the constant be applied to maintaining the positive forces.
round of talking to people and slowly influencing them. A good design is one that minimizes the number of
Given this perspective, the need for change must be an people who lose position, status or influence as a result of
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enduring one. the change and maximizes the number who stand to gain.
At the design stage, a little time spent looking forward Those who will gain may become supporters but those
can be amply repaid. When a possible design is produced, who stand to lose could become an effective opposition. A
it should be analysed in terms of the groups of people who good design also takes notice of the favourable local fac-
are likely to be in favour of it and those who will be against tors, the pathways to change, that can be a bias to success.
it, and their reasons for this. This process, called force field Good design looks at the possible hurdles or difficulties
analysis, can be really useful in gauging the strength and that must be overcome or avoided, the barriers to change,
quality of possible opposition. and tries to minimize their impact. Barriers are sometimes
The origins of force field theory lie in the systems looked upon as absolutes, as immovable constraints; e.g.
theory of organizations proposed by Kurt Lewin. This doctors do not like change. Our view is that the barriers
theory holds that the status quo in any organization, at any depend very heavily on what is being proposed and how it
particular time, is an equilibrium brought about by the is proposed; they depend on the content and style of
action of forces pushing in opposite directions. The action change.
of these forces on each other maintains the equilibrium.
For personal use only.
244
Managing change in a medical contexc
Consulc and talk to all the key individuals who can affect the
outcome of the change initiative, not once but several
Appropriateness, teamwork, talking and explaining,
times. The larger and more complex the change at-
leadership
tempted, the more effort will be needed to shift the climate
When a solution to the problem or a response to the of opinion towards acceptance and understanding.
opportunity has been designed, it is essential to consult Another way to seek to shorten the process of consul-
widely with all those touched in any way by the changes. tation is to use representatives with whom to negotiate and
discuss. This policy is also not without problems. The
The process has the benefits of receiving feedback to help
improve the proposals and involving those affected by the representatives may not have a sufficient mandate from
change more closely in the events. The only limits to their members to agree to novel arrangements and the
consultation are the time it takes and the patience of the advantages of seeing people in person and being able to
audience. It is much better to have incomplete ideas in the influence them directly are lost.
public arena than to work secretly to develop the perfect Consultation is a verbal skill. Only write to confirm
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scheme and then to spring it on an unsuspecting world. what has been agreed face to face.
and that the desired results are within the capacity of the
local resources. The consultation process is a preparation can uncover unforeseen consequences of proposed actions
for the implementation stage. and can thus allow the plans to be modified.
The aspect of consultation concerned with disseminat- Publicity is used to alter opinions and behaviour and so
ing the idea or proposal is one over which leadership can the way the changes are presented is of great significance.
be exercised. Once change has been put on the agenda, However, radical and innovative the design, it is always
events may well take on a life of their own and move in the helpful to present the changes as incremental improve-
wrong direction, unless guided by the leadership of the ments, as small changes in the previously accepted direc-
individual or team managing the change. The leadership tion. It is beneficial to present changes as experimental and
role has to find the best balance between keeping things to leave open the option of a later return to the status quo.
moving along roughly the optimum path and taking time In practice, it is hard to remove a system once established,
to consult and discuss. Leadership demands courage and but it can and should be modified according to experience.
fine judgement.
Consultation is a lengthy process. Consultation takes Establishing a change initiative as an experiment is
time, but every effort needs to be put in to make sure that an extremely effective strategy. An experiment is less
everyone important to the outcome of the change initiative threatening than an imposed change and will attract
has been contacted. It will be clear that teamwork has an less opposition. If it works, the benefits are there for
essential role to play. A team of people can do more that all to see. If it fails, the organization has not been
the sum of its members because of team spirit, the lesser irrevocably altered. .
impact of individual shortages of time or energy and the
greater source of ideas. The presence of a team working Sometimes, publicity has to be produced before too
towards change can have the effect of reducing the sus- many of the actual details have been worked out. It is here
picion of personal motives and actions and so encourage that vision, an idea of how things could be after the
commitment on the part of those affected by the change. change, or an ideal to strive for, plays a role. Such a vision
There are consequences of teamwork in terms of loss of can capture the imaginations of others and provide a very
individual control and direction of the project, but these useful anchor, to which to cling, when being tossed about
costs are outweighed by the benefits. by the turmoil that major changes can unleash. A vision
There is no effective substitute for talking to people can help to provide a guiding path through the apparent
directly and explaining to them what is going on, how they chaos that is generated by the change process. Change is
are affected and what will happen next. It may be tempting seldom a smooth process.
to devise a short-cut, to seek a way to consult with people A large change project generates a considerable curi-
without talking to them. Attempts to do so by writing to osity. A good change manager will be aware of this and
them or putting up notices will cause a later backlash of ensure that efficient channels of communication are set up
resentment. In thinking about any change, a sufficient with the community of interested parties. The choice of
budget of time and energy must be set aside to go round communication is dependent on local factors and re-
245
R. Gale &3. Grant
sources. Leaflets, posters, news-sheets, videos and meet- signifies the end of the acceptance phase and heralds the
ings have all been used to good effect. Whatever process is actual implementation stage. The change leader will al-
chosen to make the change programme public property, it ready have experienced many demands for detail that
is important to open channels for feedback. The more could not reasonably be satisfied. When a change is an-
people who can be encouraged to think about the pro- nounced, everyone, quite understandably, wants to know
posals, the richer will be their quality and the easier their exactly what it will mean to them and to their work; they
passage into existence. want to know in detail. Up to this stage, the detail has been
Feedback is valuable, but it is of diminished value an act of faith or a matter for negotiation and compromise.
unless it is used actually to amend the proposals. By now Now detailed plans have to be made.
it should be becoming clear that change is a rather fluid The process of going backwards and forwards through
process that involves large numbers of people. Successful the design, consultation and publicity stages will not have
change relies on converting the majority into supporters or attracted everyone’s agreement and this is not necessary.
even owners of the project. Listening carefully to feedback There must, however, be a critical mass of supporters who
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and being seen to respond positively to it help enormously can carry the rest of the hospital, committee or health
in gaining acceptance. It might be imagined that publiciz- organization with them. Many lingering doubts and uncer-
ing a less than perfect proposal would lead to a large loss tainties can only be dispelled in practice, once the changes
of face and consequent ridicule. In practice, this only have been implemented. The detailed plans inform all
occurs when publicizing the change with a rigid determi- individuals of their roles in the new order and provide a
nation to stick to it. If feedback is encouraged and is used, chronicle of events which is of great value in the intensive
then early publicity is a positive step. stages to follow.
The change leader has to balance the urge to get on We present below some comments on plans and plan-
with things against the need to establish a favourable ning taken from our interview survey:
climate for the proposals. It is important not to try to
People need to think what they are going to do, and how
shorten the processes of consultation and publicity because
the parts interdepend.
those missed out may well form a strong opposition.
One of the most important things in educational change
is to have the stages laid out in detail with tactics and
Agree detailed plans timescales.
For personal use only.
246
Managing change in a medical context
bits in place first. Such an opportunistic approach is a end of the process, but it is probably over halfway and
recipe for disaster because people will lose faith in changes certainly a key stage. Implementation is not the time to
that are made too incoherent and unsupported to operate. pack up the tools and set off for the next challenge. The
Implementation has to be managed in order to make the new ways of working are still a fragile flower that needs
adoption of the new system as painless as possible. nurturing and care if it is not to wither. People need help
to assume new roles and relationships, they need support
A classic implementation issue faced by many health and encouragement. Support can mean offering a helping
professionals is the need to maintain the present hand to those finding it difficult or struggling with die-hard
system and to implement a new system with effec- elements bent on sabotaging the plans.
tively no additional resources. Such an approach Even after the most exhaustive consultation there may
always slows down change, at best, and often stifles still be some who resist the changes. Resistance should not
it completely. be confused with outright opposition; it is much more
~~ mild. Resistance amounts to qualified acceptance and
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It is for these reasons that a proper strategy for im- serves a useful function in making sure that the new system
plementation has to be drawn up and discussed with the of operation achieves the highest possible standard within
key players in the drama. People will have agreed why they the resource constraints. Resistance is the enemy of com-
are changing, but they also have to know what to do, with placency and smugness.
whom and when. Sometimes when people are genuinely trying to im-
Up to this point pathways and barriers to change have plement change, they come across insurmountable
been considered in design and their impact has been difficulties, items in the plan which do not work and
minimized. At the implementation stage, any residual cannot fit in. Such difficulties must be addressed speedily
problems or unforeseen routes to success will become and steps must be taken to sort them out lest they should
apparent and active. ‘Pathways and barriers’ is a con- become a focus for opposition and attempts to reverse the
venient notation for all the good and bad aspects of the course of change. It is almost impossible to predict every
stages in change management and all the good and bad situation in advance and probably unproductive to try to
aspects of the choices of tactics and styles of leadership do so, but problems that arise need urgent treatment.
that have been adopted. We said earlier that pathways and Once the new system is in place, there may be those
For personal use only.
barriers are not absolutes, rather they are created by the who have genuine objections to it when they realize what is
ways change is presented and approached. actually involved for them. Objections are not the same as
T o provide a flavour of the sorts of things that were felt difficulties and may contain a higher emotional content. In
to be important by the participants in our study, we list a handling objections it is necessary to use judgement. The
selection below: change leader needs to hear the objections and try to be
conciliatory. At the same time it will be necessary to decide
(1) Pathways to change: whether the views represent widely held opinions or
Shock from adverse reports whether they are those of professional objectors making a
Panic due to finances last attempt to halt progress.
Tradition of innovation New methods of working are still vulnerable to re-
Professional pride gression unless the change leaders show interest and offer
Change of key staff rewards and encouragement to those operating in the new
Supportive group ways. It is not a good idea to forget about the system once
Avoiding something worse implemented, because habits will drift back to the old,
Government pressure secure ways. New methods, new procedures, new relation-
Incentives for acceptance ships take time to be learned and absorbed and they take
(2) Barriers to change: time to become the new status quo. Change leaders need
Sticking to contract tact and patience to help everyone to accept and operate
Threat to status the new system.
Protection of territory
Service commitments
Lack of reward or gain One doctor we interviewed was involved in a major
Clinical independence campaign to change the behaviour of GPs and the
Lack of will to change general public in relation to the treatment of a par-
“Not my idea” ticular disease. This doctor found it necessary to take
Cover-up of limitations a new approach about every two years in order to
prevent the initial enthusiasm from waning and the
old ways of working from returning.
Bovide support
Resistance, overcoming difficulties, objections, main-
taining change Many initiatives that have been introduced as a result
of pressure or coercion tend to wither and die out at this
During the implementation stage all thought of relaxed stage. It is difficult to maintain pressure and without
creativity can be set aside, and pragmatism and problem- support and goodwill from the majority of those involved,
solving skills come to the fore. Implementation is not the the new system cannot last.
247
R. Gale &J. Grant
and should be treated as such. But, do not despair, it is tise. For major changes, it may be feasible to enlist outside
usually a much quicker process to modify a change in professional help. For smaller changes, self-help is proba-
order to make it work properly than it is to start from bly sufficient and a relatively informal evaluation should
scratch and have to convince people of the basic need and suffice.
to negotiate the best course of action. The nature of the change process is such that it is
difficult to unleash it with sufficient energy to overcome
the inertia of the status quo and at the same time exert
completely foreseen the effects on anaesthetic proce- sufficient control over the events to be able to predict the
dures. The original plan had to be modified to allow outcomes with certainty. In the heat of battle, twists and
time for a proper assessment of suitability for turns are forced on the change leaders by events and the
surgery. change process takes on a life of its own. It is thus not
unknown for the final outcome of the change episode to be
quite other than that which was first envisaged or even
It may be that plans are being held up by the attitudes
desired. Wide ownership of the process and extensive
and actions of one or a small number of people. These
For personal use only.
Evaluate outcomes
Evaluation strategy Final thoughts
Throughout this guide, we have been concerned with Armed with a reasonable understanding of this model of
change designed to meet a perceived need or to exploit a change in a medical context, there should be less fear of
248
Managing change in a medical context
opened since you planned the journey and there may be and industrial management and has worked for several years on
accidents forcing you to stop and repair the damage. management issues in medicine, particularly the funding of re-
If you prefer to view the model as a list of action steps search, the management of medical education and the management
of change.
or checklist, then you will need to work through it and
decide which parts of it you will need to emphasize and
which parts you can safely ignore. This choice will depend Further reading
on the type of change you are contemplating, on its com- We give below an extremely selective list of the readings we find
plexity and the number of people affected by it. It is helpful. There are many books and articles on the management of
change, written from a range of standpoints, and they all contain
difficult to offer any more profound advice since the local some useful ideas.
people and the local circumstances will play a major part in BOWMAN, C. (1992) The Essence of Srrategic Managemenr (New
influencing the optimal process. We would, however, stress York, Prentice Hall).
that time spent in consulting others and talking to them DALZIEL,M.M. & SCHOONOVER, S.C. (1988) Changing Ways (New
about the need for change and the changes themselves is York, Amacom).
GRANT,J.R. & GALE, R. (1989) Changing medical education,
an investment that should be maximized. Medical Educarion, 23, pp. 252-257.
We would very much like to be able to provide a clear GALE, R. & GRANT, J.R. (1990a) Guidelines for Change in Postgradu-
set of instructions for managing any change. Unfortu- are and Continuing Medical Education (London, Joint Centre for
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