Large-Scale Change - Paul Plsek

Date: 19 May 2016

Author: Paul Plsek, AQuA Affiliate and Founding Director of the Academy for Large-Scale Change for the NHS

Insights from system leadership and complexity theories underpin successful models of large-scale, or transformational, change across organisational boundaries. Mohrman et. al. (1989) describe large-scale change as that which is pervasive (impacting the whole system), deep (challenging to traditional ways of working), and wide (in terms of geography or numbers of people impacted). This is precisely the sort of change that health care leaders and policy-makers in the UK, and around the world, are calling for.

The phenomenon of large-scale change has been widely studied, across a variety of settings (Kotter, 1995; Gunderson and Holling, 2002; Wheatley and Frieze, 2007; Keller and Aiken, 2008; Oldham, 2009; Best et. al., 2010). A recent review identified ten key themes in the literature (Bevan et. al. 2009). Successful large-scale change requires:

  1. Movement towards a new vision, fuelled by the passion that comes from the fundamental belief that there is something very different and better that is worth striving for.
  2. Identification and communication of key themes that people can get their heads around and that will make a big difference.
  3. Comfort with multiples of things (‘lots of lots’); for example, many different stakeholders, agendas (both hidden and open), points of view, needs and wants, details, systems that need change and so on. Attempts to isolate or work around some groups, or to ring-fence some parts of the system to be left alone while others must change, typically result in something less than transformational.
  4. Framing the issues in ways that engage and mobilise the imagination, energy, and will of a large number of diverse stakeholders, in order to create a shift in the balance of power and distributed leadership.
  5. Mutually reinforcing change across multiple processes and subsystems that connect with, and build upon, one another.
  6. Continually refreshing the story to create a continual stream of new supporters who become attracted to the vision when they see it progressing.
  7. Emergent planning and design, based on monitoring progress and adapting as you go; flexibility, adaptability, and engagement of others are the keys.
  8. Acceptance that outcomes are impossible to predict at a detailed level; due to the nature of complexity, not a flaw in planning.
  9. Transforming mindsets through true engagement and the belief that the new way is more desirable than the status quo, thereby leading to inherently sustainable change.
  10. Maintaining and refreshing the leaders’ energy over the long haul.


Best A, Saul J, Carroll S, Bitz J, Higgins C, Greenhalgh T, Lewis S, Bryan S, Mitton C (2010)  A Systematic Realist Review and Evidence Synthesis of the Role of Government Policy in Coordinating Large System Transformation. Vancouver: Coastal Health Research Institute.

Bevan H, Plsek PE, Winstanley L (2009) Leading Large-Scale Change: The Experience of the NHS Academy for Large-Scale Change. Warwick: NHS Institute for Innovation and Improvement.

Gunderson LH, Holling CS (eds.) (2002) Panarchy: Understanding Transformations in Human and Natural Systems. Washington: Island Press.

Keller S, Aiken C (2008) The inconvenient truth about change management: Why it isn’t working and what to do about it. McKinsey&Company briefing paper.

Kotter JP (1995) Leading change: why transformation efforts fail. Harvard Business Review March-April: 59-67.

Mohrman AM, Mohrman SA, Ledford GE et al. (1998) Large-Scale Organizational Change. San Francisco: Jossey-Bass.

Oldham J. (2009) Achieving large scale change in healthcare. JAMA 301(9):965-966.

Wheatley MJ, Frieze D (2007) How large-scale change really happens: Working with emergence.
The School Administrator, Spring.