More of the same won’t work
There is no doubt that across health and social care leaders know the system has to change. In most places and across the professional disciplines (clinical and managerial) there is agreement about what the future will look like (more coproduced care, resourceful communities, generalists better supported by specialists, care closer to home, integration, digital support for care and decision-making). As Nigel Edwards, at the Nuffield Institute for Health says, somewhere between what we know about the current and an agreed future there is a vacuum where ‘magic happens’.
Getting from here to there is not simple, and in frustration about the complexity of leading change the old world bites back – the NHS puts in structures, hierarchical governance and project management, the sorts of processes that work for ‘tame’ problems not for ‘wicked’ problems, for markets and hierarchies, not for collaboratives and innovation. Its clear that this is not working. The temptation is to just keep on trying do get innovation going, but I think we have to address some of the key underlying tensions and issues:
- The sense that ‘Innovation’ is soft and might not work and ‘Performance Management’ is proper management and will work.
- The demise of professional practice review. Clinical leadership hasn’t as yet managed to secure clinically-facing data for improvement, innovation and clinical decision-making, or time to review practice as routine.
- The only way to collaborate is to cede individual (organisations) territory and individual (leaders) power.
The tensions between performance management and innovation
The literature from high-performing health systems tells us that the process of data generation and measurement, and associated knowledge generation is different for performance measurement than it is for innovation. High performing health systems invest in, and give significant attention to measurement for improvement and innovation.
This widely cited model from Berwick et al (2003) demonstrated the difference between measurement for selection (in the diagram measurement for judgement and choice) – a top down, performance management approach; and measurement for Innovation and change – a bottom up, granular level improvement and professional review approach.
In the UK this dynamic becomes translated into a model of the management of risk with the tension being between safety / assurance and innovation, through a management lens. There is less discussion of the nature of professionalism in health and social care to achieve quality (and efficiency). In high performing health systems, professionals lead innovation. Improvement, scrutiny, review are all actions of professional practice, which secures improvement in quality.
A recent ipso Mori poll for the Future-Focused Finance Initiative, of finance and clinical staff in the UK, cited 24% of respondents were able to take time to reflect on how they were doing as a team. Recently Peter Lees (2016) identified that in his view “Reluctance by doctors to engage in management and leadership at other than the clinical team level is prevalent”(p5). An example of a symptom of the balance of attention in the UK between the power of performance management for change versus the power of innovation and improvement for change is evident in the work of data analysts and scientists. In Intermountain healthcare, data underpins all clinically facing decisions as well as managerial decisions. Every clinical directorate team is supported by data scientists, providing granular data for clinical review and decision making. In the UK our data capacity is clearly focused on performance management data generated by analysts, not data to support great decisions between professionals and citizens supported by scientists.
Ceding power and territory
Health and social care struggles between the need for local solutions and locality based provision and delivering a national service. It is an age-old dilemma but in the context of innovation it comes into sharp relief. The devolution agenda hints at more localism and self-determination, but the structural and governance models emerging feel more like a centralist response. Devolution should mean thriving local economies with real citizen involvement (NEF 2016). In fact in high performing health systems – localism (local population based needs approaches) are at their heart from Nuka to Burtzoog to Jönköping.
A recent paper on integration (Hussein and Dornhost 2016) for the Royal College of Physicians Future Hospital Programme explores the early work on population based integration bringing hospitals into the population model, requiring local collaborative networks, and the challenges for medicine. The Accountable Care Systems, Alliance Contracting, Sustainability and Transformation Plans, Vanguards Academic Health Science Networks and Collaboratives all emerging across the health and social care system, demonstrate a move to networked organisations and delivery models. This is a global trend with many organisations have both hierarchical working and agile network working (Shuman and Twombly 2009)  .Moreover interviews with CEOs in the UK (Leadership Indaba report) shows that there is a real struggle in one of the key factors required in leading networks, and critical from the evidence from high-performing health systems (Baker & Denis 2011) –ceding territory and power. At the launch of the Collaboration Toolkit, the tension between finance being Finance Director’s responsibility and gift, rather than it being a collective Board responsibility was palpable, alongside concerns that innovation was ‘soft’ and performance management ‘trustworthy’. Working out how hierarchical models of individual and organisational authority, can move to collective responsibility, and collaboration, is hard; doing it in the context of a politically charged service and a range of ideologies about ‘localism’ is a challenge.
The cultural conditions for innovation
The context describe points to a number of cultural causalities that shape the innovation landscape:
- The reluctance to move from a performance management model of securing change to an innovation model
- The impact of policy, and the internal dynamics of the (clinical) professions in terms of the nature of professional leadership and practice in the UK
- The move to more agile networks as organising forms
- The need to cede power to secure population-based locally driven innovation.
 Lees P 2016. Clinical Leadership- are clinicians up for it. Clinical Medicine. Journal of the Royal College of Physicians. February 1, vol. 16 no. 1 5-6
 Hussein S, Dornhorst A (2016) Integrated care – taking specialist medical care beyond the hospital walls. A report to the Royal Collage of Physicians Future Hospital Programme. Royal College of Physicians, London, February
 Shuman J & Twombley J, 2009, “Collaborative Networks are the Organisation. An Innovation in Organization Design and Management.” CollaborativeBusiness (July): pp 2-24. Volume 8 in White Paper Series. Newton MA: The Rhythm of Business
 Baker GR, Denis JL. 2011 A Comparative Study of Three Transformative Healthcare Systems: Lessons for Canada. Canadian Health Services Research Foundation