The company’s management has to understand how to deal with all the stakeholders, how to utilize the drivers for change and how to avoid the barriers for the company to achieve the intended changes. In an attempt to understand the stakeholders of the Mid-Staffordshire NHS Trust, this study performed a stakeholder analysis in which the major stakeholders were listed and analysed. The major stakeholders include patients, management, government, staff, provider trust board, healthcare payers (insurance companies, regulators, and the scrutiny groups). An analysis, using the stakeholder matrix, had classified the stakeholders into four different categories. The first category contains stakeholders with low interest and low influence. The second category comprises of stakeholders withlow interest in the project, but possesses high power of influence. The third category is that of stakeholders with high interest and low power, while fourth category comprises high interest and high power individuals. Meanwhile, the company’s stakeholders have a source, where they derive their power. In the case of the Mid-Staffordshire NHS Trust, there are three sources of power for the stakeholders. These sources of power include legitimate power, expert power, and reference power. Together with the stakeholders, there are factors referred to as driver for change that enables an organization to move towards attaining its goals. Drivers for change can be classified as either internal driver or external driver. The internal drivers for change at the Mid-Staffordshire NHS Trust include culture, customer satisfaction, employee morale, financial management and desire to expand, whereas the external drivers are political influence, standards, and competition. However, there are barriers that work to hinder the organization from achieving its goals or implementing the necessary changes. These barriers include the organization’s culture, lack of communication between the players, low standards, assumptions, and excessive tolerance.

Leadership and Change Management

Changes that affect their organizations are one of the daunting tasks that the management faces. In most cases, the organization’s administration faces opposition to change from within than vice versa. It is rare to have resistance from outside the organization, and if it occurs, it is easier to resolve. Nevertheless, it takes strong leadership and management skills to manoeuvre and steer the company towards achieving the set goals. The success of any project in an organization depends on how the management involves the stakeholders, how they utilize the drivers of change and how the company avoids the barriers to the set changes. Most organizations fail because the leadership did not appreciate the role played by every stakeholder. Using the case of the Mid-Staffordshire NHS Trust, this study demonstrates how failure to appreciate all the stakeholders, drivers and barriers to change can result in the downfall of the entire organization.

Stakeholder Analysis of the Mid-Staffordshire NHS Trust

Before performing the stakeholder analysis, it would be better to understand who the stakeholder is. Wit and Meyer (2010, p. 175) define a stakeholder as an individual, who can affect the firm’s profitability and help it to survive. In this study, a stakeholder is defined as a person who impacts or who is impacted by the organizational activities. He or she is, therefore, a beneficiary or a risk bearer for the activities of the given firm. The Mid-Staffordshire NHS Trust include: the patients, the management, the government, the staff, the provider trust board, the healthcare payers, such as the insurance companies, the public, regulators and professional bodies, the agencies, the scrutiny groups, and the commissioners (Francis 2013, p. 1620). For the sake of this analysis, the current study groups these stakeholders into major and minor stakeholders. The major stakeholders are the patients, the management, the government, the staff, the provider trust board, the healthcare payers, such as the insurance companies, the regulators, and the scrutiny groups.

Stakeholder Matrix






Lack interest and power.

They can easily be influenced.

More likely to accept information without questioning.

Are interested in the activities, but lack the power to interfere.

Need to be convinced of any plan that is being undertaken.

May try to gain power if they feel side lined.



Have the power to influence changes, if dissatisfied.

However, they do not show the desire to get involved.

They need to be reassured to prevent them from exercising their power.

They are the primary drivers of the change.

They can significantly interfere with the changes, if dissatisfied.

Management need to consult them before taking any steps.

They can easily derail a project.


Table 1. Stakeholder Matrix. This table shows the four classes of stakeholders with regards to their interests and power (Kimmich 2012). 

Powers and Interest Held by the Stakeholders

Using the stakeholders’ matrix, this study classifies all the major stakeholders and then advises on the how they should be dealt with to avoid conflicts.


The patients are the most important stakeholders in the healthcare setting. They are entitled to receiving quality treatment. These interests are, however, connected to the benefit of other players such as the healthcare payers. The interest of the patients may conflict with the interest of the payers, such as the employers or insurance companies, when the patient expects the payer to offer a wide variety of coverage options to fund the majority of the cost. Although, the patients cannot demand to know everything that is going on in the healthcare system, they have to be informed of the activities that concern them. Patients certainly need to be informed because they will be involved in the project implementation stage; without patients the project would fail. Intrinsically, the patients have limited power in the form of withdrawal or taking legal actions towards the offenders. Therefore, in the stakeholder matrix, patients are classified as a group with high influence and high power and, thus, their needs have to be satisfied.

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Mid-Staffordshire Foundation Trust

The management expects that the services they provide to the patients are effective and helpful. Given that the Mid-Staffordshire foundation trust runs the hospital on behalf of the government, they are the ones who control the strategic resource. Their role in the project is to ensure that the customers receive services that are worthy of the amount that they pay. However, the interest of the management may be in conflict with that of the patients when they begin to focus more on money they generate, rather than the quality of the services that they provide. Unlike the other stakeholders, the management cannot be classified using the stakeholder’s matrix. However, they need to create a good relationship with the other stakeholders to enable them to run the project smoothly.


Though the government does not have a direct interest in the healthcare provision, it is an important member of the stakeholder’s group. NHS foundation trusts devolve decision making from the government to the local community, thus the government expects them to provide services to people without pay. It was expected that, as a healthcare provider, the NHS healthcare foundation would consult the government on all of its plans. To ensure that the project is safe for its citizens, the government must be involved in the assessment and evaluation processes. As a policy maker and with the duty to evaluate and assess any project that is launched, the government is a key player and can be classified as a stakeholder with low interest, but with high influence in the stakeholder’s matrix.


The staff members are the second most important stakeholders, as they are the ones directly responsible for the project’s implementation. Staff members are tasked with the duty of taking care of the patient and ensuring that the customer gets quality services. In the case of new medication or treatment available, they are the ones who advise patients on the right kind of treatment. The staff’s interest is in payment, and, thus, they expect to be paid well by the management. They are the ones in possession of the specialist knowledge that is required to serve the customers. As such, customers are considered partners in running the healthcare facility. In terms of influence, they can be considered as the gatekeepers. Though they have low power, the staffs have high interest in the operations and, for that matter, they must be convinced on any activity that is taking place.


The payers can be in the form of an insurance company or the employer. Given their varied nature, the payers have varied interests. However, all their interest can be summed up to make a profit. For example, the interest of the insurance company is to receive the patients’ premium, but to pay low to cover the cost of treatment. The payers may want to maintain or lower the cost of contribution, which can be contrary to the patient’s interest. They are not directly involved in the process, and, thus, they have low power and low interest. As such, management needs to keep these stakeholders updated about the project.

Regulators and the Scrutiny Groups

The regulators play the leadership role, while the scrutiny group plays the role of gatekeepers. Regulators scrutinize the project and, thus, are involved in the project’s assessment. Scrutiny groups do not have a direct interest in the project, but they have links with other stakeholders, such as the government and the patients. They are independent and cannot be controlled or influenced by other stakeholders (Banfield & Kay 2011). Though the scrutiny groups have low interest, they have the power to influence changes, if dissatisfied for some reason. Scrutiny groups need to be reassured, so as to prevent them from exercising their power.

Sources of Stakeholder Power

Leadership, on the one hand, is a process through which an individual, through his influence, leads others to achieve a common goal (Northouse, 2013). Power, on the other hand, can be described as the ability of an individual to influence others to support him or her in the bid to achieve a given target.The sources of stakeholder power include: legitimate power, expert power, and reference power.

Legitimate Power

Legitimate or positional power is derived from the position that one holds in the hierarchy of the organization (Bacon 2011, p. 134). The person having this power must have earned it legally, either through professional qualification or through experience. Positional power gives a person the authority to play a supervisory role. In the case of the Mid-Staffordshire foundation trust, the government and the management have derived their power from the legitimate power.

Expert Power

Expert power is the type of power that is derived from the leader’s possession of knowledge or expertise he/she holds (Bacon 2011, p. 161). Leaders with expert or specialist power form an integral part of an organization. People with specialist power are highly influential, as their opinion is often held in high regard. Taking a look at the stakeholders in the case study, the staffs, the payers, and the scrutiny group derive their power from the expert power.

Reference Power

Reference power is derived from the interrelationship between people in a given organization. This power is derived from a personal connection that one may have with the leaders in an organization (Northouse 2015, p. 116). The patients derive the reference power by forging a relationship with the management and the staff.

Drivers for Change at the Mid-Staffordshire NHS Trust

Business leaders occasionally seek for ways and methods on how to improve strategy and how to transform their operation in order to boost their performance. Changes can be undertaken in the form of human resource, facilities, business strategy or the business process. Roberts (2007, p. 7) pointed out that a holistic change is much desirable over a strategic change. A variety of factors can cause an organization to initiate the changes to its operations. In this paper, we examine the factors for change at the Mid-Staffordshire NHS Trust. The factors are further grouped as either internal or external.

Internal Drivers

Internal drivers are factors that can cause changes in an organization, but are under the control of the organization’s management. At the Mid-Staffordshire NHS Trust, the internal drivers for change include: culture of the organization, customer satisfaction, employee morale, financial management and the organization’s desire to expand.

Customer Satisfaction

Customer satisfaction is a measure of how the services of a given company meet the need of its customers. It pushes the management of a company to make the necessary changes, so as to attract more customers and earn more profit. At the Mid-Staffordshire NHS Trust, the level of customer satisfaction was low due to the poor customer service. The report by Francis (2013, p. 1548) accuses the management of failing to listen to the patients.

Employee Morale

The level of morale among the employees is very important in any company. If the employees are demoralized, they produce a low output, which then impacts the general output of the company. On the contrary, satisfied employees are productive (Trades Union Congress 2017). The employee morale at the Mid-Staffordshire NHS Trust was low and is among the factors that resulted in poor service delivery. For example, according to the report by Francis (2013, p. 1361), among the factors that were blamed for poor performance of the trust board was the management’s disengagement from responsibilities. Moreover, the Mid-Staffordshire NHS Trust board was also accused of not listening to its staff.


Culture is the behaviour and attitude of individuals and group within a company. Organizations with good culture often thrive, as opposed to those with bad culture. Lousy culture negatively affects the production of a company and even its reputation is making it difficult for the company to compete with others. The culture of the Mid-Staffordshire NHS Trust puts more weight on positive information than on the negative information that requires their attention. Besides, it tolerated poor standards and focused on doing the system’s business, rather than meeting the needs of patients. The failures in the Mid-Staffordshire NHS Trust can mainly be attributed to lousy culture mentioned here.

Financial Management

Finance is always the primary focus of a business. Financial management calls for the administration to make a decision on the direction that the company wants to take with regards to funds. Changes in the Mid-Staffordshire NHS Trust were induced by the aspiration to achieve financial balance. The management made financial balance their main goal and aborted the main objective, which is to ensure the safety of the patients.

Desire to Expand

The first goal of every organization is to grow and to expand. Just like any other organization, the Mid-Staffordshire NHS Trust had this passion, and, as a result, they lost focus on their primary objective. They focused on receiving a national stature and recognition, instead of delivering quality care. This desire for growth made the trust to focus on raising the profit and failing to pay attention to areas that required improvement.

External Driving Force

External drivers are factors outside the organization, but they can cause changes to the manner in which business is conducted within an organization. At the Mid-Staffordshire NHS Trust, the external drivers for change include: political influence, standards, and competition.

Political Influence

Politics have a direct influence on the business’ functioning. Political players have the powers to make and amend laws that impact on the operations of the business community and the health sector. In case of the Mid-Staffordshire NHS Trust, the new reforms have created a new system and institutional constraints. Also, the management of trust is focused on achieving national stature at the expense of patients’ safety.


Standards are the bench line for the quality of services that a firm is expected to deliver. Companies initiate changes, in order to meet the required set standards. In the case of the Mid-Staffordshire NHS Trust, the standards were not met. As indicated in the report by Francis (2013), there are checks and balances, agencies, regulators, and scrutiny groups, all in place to ensure that the required standards are met. The report concludes that the scandal occurred because all these entities are responsible for keeping the Mid-Staffordshire NHS Trust in check failed.


Every business entity faces some kind of competition. As such, the management has to come up with strategies to outperform their competitors. Competition can cause a company to initiate the changes. In the case of the Mid-Staffordshire NHS Trust, the changes were instituted as a result of demands for corporate governance. Besides, the company lost focus for its goal, as it was competing for financial control to enable that it attains the foundation trust status.

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Barriers to Change at the Mid-Staffordshire NHS Trust

For any change to be successful, the organization management must find a way of overcoming the barriers that hinder the achievement of these changes. Barriers are factors that deter the firm from smoothly implementing the intended changes (Carberry & Cross 2015, p. 92). The Mid-Staffordshire NHS Trust was expected to change from its money-oriented approach to a patient-centred approach. However, various factors led to the failure of the Mid-Staffordshire NHS Trust to make the changes. These factors include the organization’s culture, lack of communication between the players, low standards, assumptions, and excessive tolerance.


Organization’s culture can either boost or hinder the implementation process of changes. Those who are against changes often claim company culture to be the reason why they do not want the changes to be implemented. According to the report by Francis (2013, p. 1561), culture was often blamed for the downfall of the Mid-Staffordshire NHS Trust. The facility had the culture of reluctance. They were reluctant to focus on the negative information that would have alerted them that something was wrong. Instead, they only focused on the information that boosted their business. Also, the management was too reluctant to tackle the challenges to building up the problem. The culture of being money oriented is also a barrier to quality care delivery. For example, according to the report, the trust focused on doing system’s business, rather than focusing on caring about the patient.

Lack of Communication between the Players

Constant communication between all players is necessary for the project’s success. Lack of communication creates a hindrance to the smooth running of any project. If there is a good communication flow, every player knows his/her role, and, thus, there are minimal chances of failure due to omission. In this case under study, there was a lack of communication between the concerned agencies. Due to a lack of proper communication, the agencies failed to share their knowledge of concern.


In some cases, lack of communication causes too many assumptions. People may ignore doing a given task and assume that the other person has done it. Assumption leads to negligence. Assumption is, therefore, a barrier to change in that it slows the pace of the change process. In the case of the Mid-Staffordshire NHS Trust, the assumption made it difficult for the regulators, professional bodies, agencies, scrutiny groups, and the commissioners to monitor the management’s performance. They all assumed that monitoring and intervention was the job of another person.

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Low Standards

Every organization has standards it has set to achieve. Organizations that have set high standards often produce high quality products. The standards set by the enterprise can be a hindrance to change, as the employees may not be willing or ready to adjust to them. For example, a company with high standards will receive resistance from its stakeholders, due to fear that the change would lower the standards and lead to the production of poor quality of services. Even where the changes are intended to raise the standards, there is likely to be resistance from the lazy employees. The standards at the Mid-Staffordshire NHS Trust were too low that it made it difficult for scrutiny groups to measure compliance.

Too much Tolerance

Tolerance is the willingness to allow something to happen to a particular extent. Tolerance can affect an organization, as it may be interpreted to mean weakness or carelessness. Too much tolerance can be a barrier to changes, since the management may be reluctant to follow the rules that are required for the implementation of changes to the latter. The Mid-Staffordshire NHS Trust management was accused of being too tolerant in addressing issues that the trust was facing. This culture of tolerance prevented the organization from delivering quality services to its customers. The level of tolerance shown by the Mid-Staffordshire NHS Trust towards disengagement by the members of the management affected the way the organization approached the issue of risk in patients’ lives.

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