Shaping Culture

The NHS has a number of its own Consulting teams which operate in a similar way to any other professional consultancy, bidding for contracts and supporting clients to deliver small and large transformations. For three years, I worked for one of the most successful of these, NEL Healthcare Consulting (NHC) and had the opportunity to introduce the After Action Review (AAR) approach whilst there.


Along the way I learnt many valuable lessons which I now bring to my work with iTS-Leadership as I leave behind a team where AAR is an everyday activity and exciting things are happening as a result.

Two people in the NHC senior management had trained as AAR Conductors before I joined, and thus my expertise in this area was recognised in my interview, however it still took time and energy to warm up the whole team to “the AAR way”. Most of our clients at iTS-Leadership choose to “buy in” iTS AAR Conductor Development and our expertise in embedding AAR into a companies’ culture. This leadership decision to invest in iTS AAR comes when there is real understanding in its value in enhancing the people part of performance, which in turn drives its integration. When I began, I didn’t have any such Senior Management Team understanding, so when I organised the first AAR Conductor training days at NHC, I funded them by including fee paying delegates from elsewhere in the NHS and Higher Education. The good news about this approach is that it worked and has demonstrated how AAR can be successfully introduced almost by stealth, from the bottom up, and yet the most interesting aspect for me has been that the barriers and enablers to embedding the approach are much the same as the “buy-in” model iTS-Leadership client’s use.

The similarities between the “bottom up” and the “buy in” approaches include: –

  • The first AARs tend to be held because things have gone wrong or something unexpected happens.

An example of this was when one of the NHC office buildings had to be evacuated as local building works had affected the water supply. The AAR led to valuable learning about the Business Continuity Plan and its implementation over 2 days. The potential to use AAR for learning from any shared experience, not just the most challenging, seems to have to come later in the integration process.

  • At the early adoption stage, the participants’ experience of AARs invariably exceed their expectations.

At the end of AARs as people leave the room, there are frequently comments like “That was better than I was expecting” and “That was actually really helpful”. I think this speaks of the widespread fear of talking truthfully about events, the concern that someone will be blamed, together with the dread that it might be them(!), as well as the poor quality of so many of the meetings they attend.

  • Those who lead AARs (The Conductors) quickly understand the complexity of the group learning process they are facilitating.

An AAR is a very different type of meeting where the conductor has to ensure all contribute, “air time” for the most senior or extrovert individuals is tightly managed and a real depth of insight is generated using the advanced facilitation techniques specific to AAR. In addition, Conductors may be of a more junior rank than many of the AAR participants and the topic being explored may have uncomfortable associations attached. All the Conductors I’ve ever worked with acknowledge the importance of the skills they’ve acquired through training as well as the confidence that grows through experience.

  • The AAR Conductors gain significant new insights into themselves, how groups work and their own organisation.

The AAR Conductors at NHC have grown professionally through every AAR they have led, and that learning has spread out into many areas of their lives. For example, one new AAR Conductor said that the first question in the AAR process, the Expectation question had opened her eyes to a recurring problem. She recognised that she was holding unrealistic expectations of her manager and of an older brother and by adjusting her expectations she had reduced her stress levels considerably. Other AAR Conductors have described how their AAR skills in asking good questions have led to better project planning and more detailed understanding of risks and mitigations.

The main difference between the two approaches to introducing AAR is in the rate of integration into the culture. When leaders commission AAR Conductor training, actively champion and call AARs and use AAR themselves, the benefits come sooner. It took me three years to reach the “tipping point” where AAR is fully embedded and sustainable at NHC whereas some of our clients at iTS Leadership achieve it in less than a year.

Today AAR is helpfully used by NHC Consultants, not just when things have gone wrong, but also at the start of projects, (Before Action Reviews) ensuring that the expectations are fully aligned, and problems anticipated. The team have also progressed to using AAR midway as well at the end of projects, so are able to continuously improve what they are doing and maintain cohesion and focus. All this AAR activity has an important secondary benefit as it increases the rate of learning for all the consultants in the team. This is particularly valuable for NHC, as it continues to grow in size (from 30 to 70 people over the past 3 years) and due to the breadth of its portfolio across the NHS, IT and the Third Sector.

Interestingly NHC now also regularly invites clients to participate in the AARs so that a richer level of understanding is reached by all and the actions decided upon are directly relevant. Most exciting of all, of course, is the very positive impact on the quality of patient care because of the generation of valuable learning between different teams and organisations in the wider NHS. In this most complex of operating environments, AAR has an important role to play and NEL Healthcare Consulting has been the lead driver here.


In summary AAR at NEL Healthcare consulting has:-

United the team in giving them a defined approach to learning from experience.

Ensured that the high quality of learning from experience generates that all powerful “New Power”* of the crowd to bring about meaningful change.

Enabled individuals to advance in their professional lives.

*New power: How anyone can persuade, mobilize, and succeed in our chaotic, connected age. By Jeremy Heimans & Henry Timms Feb 2019

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